Provider Demographics
NPI:1902217334
Name:MARSH, JACK (DO)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:MARSH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 E. ROOSEVELT ST.
Mailing Address - Street 2:MARICOPA INTEGRATED HEALTH SYSTEM
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008
Mailing Address - Country:US
Mailing Address - Phone:602-697-0282
Mailing Address - Fax:
Practice Address - Street 1:6350 S MAPLE AVE
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-2857
Practice Address - Country:US
Practice Address - Phone:803-455-4004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-20
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0068012084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry