Provider Demographics
NPI:1417946609
Name:JELLIFFE, AMY (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:JELLIFFE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2187 N VICKEY ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-6106
Mailing Address - Country:US
Mailing Address - Phone:928-714-6409
Mailing Address - Fax:928-714-6480
Practice Address - Street 1:454 SAINT MICHAELS DR STE 200
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7602
Practice Address - Country:US
Practice Address - Phone:505-303-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ252712084P0800X
NM94-712084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
103593Medicare ID - Type Unspecified
F89678Medicare UPIN