Provider Demographics
NPI: | 1861469322 |
---|---|
Name: | JEANNETTE, MICHELLE (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | MICHELLE |
Middle Name: | |
Last Name: | JEANNETTE |
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: | 7750 E BROADWAY BLVD STE A200 |
Mailing Address - Street 2: | |
Mailing Address - City: | TUCSON |
Mailing Address - State: | AZ |
Mailing Address - Zip Code: | 85710-3901 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 520-327-1529 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 7750 E BROADWAY BLVD STE A100 |
Practice Address - Street 2: | |
Practice Address - City: | TUCSON |
Practice Address - State: | AZ |
Practice Address - Zip Code: | 85710-3901 |
Practice Address - Country: | US |
Practice Address - Phone: | 520-327-1529 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-03-03 |
Last Update Date: | 2023-11-29 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
WA | MD00036503 | 207R00000X, 2084P0800X |
AZ | 22443 | 2084P0800X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
AZ | 191007 | Medicaid | |
AZ | 22443 | Other | ARIZONA MEDICAL BOARD |
WA | 8228892 | Medicaid |