Provider Demographics
NPI:1164885711
Name:GRESHAM, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GRESHAM
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 1:4600 S MILL AVE
Mailing Address - Street 2:STE 280
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-6850
Mailing Address - Country:US
Mailing Address - Phone:480-305-2888
Mailing Address - Fax:480-305-2889
Practice Address - Street 1:1343 N ALMA SCHOOL RD
Practice Address - Street 2:SUITE 160
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5941
Practice Address - Country:US
Practice Address - Phone:480-963-1853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-31
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP8433363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily