Provider Demographics
NPI:1205086261
Name:JACO, BETH LOUISE (CPNP)
Entity type:Individual
Prefix:MS
First Name:BETH
Middle Name:LOUISE
Last Name:JACO
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:MS
Other - First Name:BETH
Other - Middle Name:LOUISE
Other - Last Name:JACO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CPNP
Mailing Address - Street 1:2680 S. VAL VISTA DRIVE
Mailing Address - Street 2:SUITE 167, BLD 12
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295
Mailing Address - Country:US
Mailing Address - Phone:480-857-0222
Mailing Address - Fax:480-857-0200
Practice Address - Street 1:2680 S. VAL VISTA DRIVE
Practice Address - Street 2:SUITE 167, BLD 12
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295
Practice Address - Country:US
Practice Address - Phone:480-857-0222
Practice Address - Fax:480-857-0200
Is Sole Proprietor?:No
Enumeration Date:2008-09-26
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN073431163WP0200X
AZ197363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WP0200XNursing Service ProvidersRegistered NursePediatrics