Provider Demographics
NPI:1154666030
Name:BASS, JENNIFER JAY (LM, CPM)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JAY
Last Name:BASS
Suffix:
Gender:F
Credentials:LM, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6260 E SADDLEBACK ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85215-9639
Mailing Address - Country:US
Mailing Address - Phone:480-440-0502
Mailing Address - Fax:480-499-5599
Practice Address - Street 1:6260 E SADDLEBACK ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85215-9639
Practice Address - Country:US
Practice Address - Phone:480-440-0502
Practice Address - Fax:480-499-5599
Is Sole Proprietor?:No
Enumeration Date:2012-12-04
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLM167176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife