Provider Demographics
NPI:1134499866
Name:SAGE, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SAGE
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 1:2502 N DODGE BLVD
Mailing Address - Street 2:SUITE 190
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-2671
Mailing Address - Country:US
Mailing Address - Phone:520-617-0043
Mailing Address - Fax:
Practice Address - Street 1:2502 N DODGE BLVD
Practice Address - Street 2:SUITE 190
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-2671
Practice Address - Country:US
Practice Address - Phone:520-617-0043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-11
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3994103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist