Provider Demographics
NPI:1609174481
Name:AHL, JESSICA JANE (LAC, MSOM)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:JANE
Last Name:AHL
Suffix:
Gender:F
Credentials:LAC, MSOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 E MISSOURI AVE
Mailing Address - Street 2:A-100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-2914
Mailing Address - Country:US
Mailing Address - Phone:602-284-9934
Mailing Address - Fax:
Practice Address - Street 1:1215 E MISSOURI AVE
Practice Address - Street 2:A-100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2914
Practice Address - Country:US
Practice Address - Phone:602-284-9934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-03
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0738171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist