Provider Demographics
NPI:1275895690
Name:ENDRES, JESSICA NICOLE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICOLE
Last Name:ENDRES
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 1:2450 S EL DORADO
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-7306
Mailing Address - Country:US
Mailing Address - Phone:602-421-7055
Mailing Address - Fax:
Practice Address - Street 1:1672 W 700 S
Practice Address - Street 2:SUITE D
Practice Address - City:SPRINGVILLE
Practice Address - State:UT
Practice Address - Zip Code:84663-4963
Practice Address - Country:US
Practice Address - Phone:801-489-9721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ184371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program