Provider Demographics
NPI:1598077372
Name:REGNAERT, JESSICA (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:REGNAERT
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 1:1917 SOUTH CRISMON ROAD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85208
Mailing Address - Country:US
Mailing Address - Phone:480-610-7100
Mailing Address - Fax:480-610-7115
Practice Address - Street 1:2927 N 7TH AVE
Practice Address - Street 2:ST. JOSEPH'S FAMILY MEDICINE CENTER
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4102
Practice Address - Country:US
Practice Address - Phone:602-406-3153
Practice Address - Fax:602-406-7176
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-08
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR71959207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZR71959OtherTRAINING PERMIT