Provider Demographics
NPI:1396773057
Name:MYERS, JENNE GARRETT (MD)
Entity type:Individual
Prefix:
First Name:JENNE
Middle Name:GARRETT
Last Name:MYERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNE
Other - Middle Name:
Other - Last Name:GARRETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4811 E GRANT RD
Mailing Address - Street 2:STE 261
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2771
Mailing Address - Country:US
Mailing Address - Phone:520-297-1345
Mailing Address - Fax:520-297-3539
Practice Address - Street 1:5670 N PROFESSIONAL PARK DR
Practice Address - Street 2:SUITE 100
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-7878
Practice Address - Country:US
Practice Address - Phone:520-618-1010
Practice Address - Fax:520-784-7040
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33821208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ946121Medicaid
I09044Medicare UPIN
AZ117605Medicare PIN