Provider Demographics
NPI:1811538507
Name:HERRON, JODY BROOKE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:JODY
Middle Name:BROOKE
Last Name:HERRON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2277
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86003-2277
Mailing Address - Country:US
Mailing Address - Phone:928-556-0060
Mailing Address - Fax:
Practice Address - Street 1:3150 N WINDING BROOK RD
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-0972
Practice Address - Country:US
Practice Address - Phone:928-774-7106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical