Provider Demographics
NPI:1164076022
Name:JARA GOMEZ, JENNIFER TATIANA (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:TATIANA
Last Name:JARA GOMEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:TATIANA
Other - Last Name:JARA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:MARANA
Mailing Address - State:AZ
Mailing Address - Zip Code:85653-0188
Mailing Address - Country:US
Mailing Address - Phone:520-682-4111
Mailing Address - Fax:520-616-1442
Practice Address - Street 1:1856 E INNOVATION PARK DR
Practice Address - Street 2:
Practice Address - City:ORO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85755-1963
Practice Address - Country:US
Practice Address - Phone:520-825-7111
Practice Address - Fax:520-818-1253
Is Sole Proprietor?:No
Enumeration Date:2019-07-30
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ65852208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ160205Medicaid