Provider Demographics
NPI:1376186692
Name:ISBELL, JEREMIAH D (PSYD)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:D
Last Name:ISBELL
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 W VILLA RITA DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-1439
Mailing Address - Country:US
Mailing Address - Phone:602-570-4038
Mailing Address - Fax:
Practice Address - Street 1:777 E MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2830
Practice Address - Country:US
Practice Address - Phone:602-570-4038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-18
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4884103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist