Provider Demographics
NPI:1124577515
Name:VALENZUELA, JESSICA JALISE (PHARMD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:JALISE
Last Name:VALENZUELA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8862 W MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85305-6934
Mailing Address - Country:US
Mailing Address - Phone:480-206-3712
Mailing Address - Fax:
Practice Address - Street 1:6601 W INDIAN SCHOOL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85033-3339
Practice Address - Country:US
Practice Address - Phone:623-846-0622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-26
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS022197183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist