Provider Demographics
NPI:1740766567
Name:DEFAZIO, JASA (COTA/L)
Entity Type:Individual
Prefix:
First Name:JASA
Middle Name:
Last Name:DEFAZIO
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7340 E LEGACY BLVD UNIT H4005
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-6531
Mailing Address - Country:US
Mailing Address - Phone:484-400-1342
Mailing Address - Fax:
Practice Address - Street 1:2175 N ALMA SCHOOL RD STE A106
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-2882
Practice Address - Country:US
Practice Address - Phone:480-855-0474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-15
Last Update Date:2018-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTA-0465882080P0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA946932790OtherUNITED HEALTH CARE