Provider Demographics
NPI:1114680394
Name:RASMUSSEN, JENICA ANN
Entity Type:Individual
Prefix:
First Name:JENICA
Middle Name:ANN
Last Name:RASMUSSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:744 E WINDSOR DR
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-4113
Mailing Address - Country:US
Mailing Address - Phone:801-674-3533
Mailing Address - Fax:
Practice Address - Street 1:1901 E UNIVERSITY DR STE 200
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85203-8308
Practice Address - Country:US
Practice Address - Phone:480-999-7911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-14
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ265327207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine