Provider Demographics
NPI:1255771101
Name:SANDER, JENNA M (CNM)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:M
Last Name:SANDER
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2683 E RUNAWAY BAY PL
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85298-0044
Mailing Address - Country:US
Mailing Address - Phone:480-619-2548
Mailing Address - Fax:
Practice Address - Street 1:18933 E SAN TAN BLVD STE 125
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-2001
Practice Address - Country:US
Practice Address - Phone:480-456-0551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN189286367A00000X
AZAP7492367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ280470Medicaid
AZPENDINGMedicaid
KSPENDINGMedicare PIN