Provider Demographics
NPI:1447222328
Name:AGENBROAD, JACQUELINE LEA (NP)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:LEA
Last Name:AGENBROAD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
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Mailing Address - Street 1:12895 W PASADENA AVE
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD PARK
Mailing Address - State:AZ
Mailing Address - Zip Code:85340
Mailing Address - Country:US
Mailing Address - Phone:623-935-2373
Mailing Address - Fax:623-932-4558
Practice Address - Street 1:1300 N 12TH ST
Practice Address - Street 2:SUITE 407
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2848
Practice Address - Country:US
Practice Address - Phone:602-239-6762
Practice Address - Fax:602-239-5112
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZRN097748363L00000X
AZNP290363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner