Provider Demographics
NPI:1720336910
Name:VALLE, JETTA (MSN, PMHNP-BC, FNP-B)
Entity Type:Individual
Prefix:
First Name:JETTA
Middle Name:
Last Name:VALLE
Suffix:
Gender:F
Credentials:MSN, PMHNP-BC, FNP-B
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3033 N CENTRAL AVE STE 145
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2808
Mailing Address - Country:US
Mailing Address - Phone:623-583-3001
Mailing Address - Fax:623-974-6721
Practice Address - Street 1:1705 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201
Practice Address - Country:US
Practice Address - Phone:877-809-5092
Practice Address - Fax:480-718-9477
Is Sole Proprietor?:No
Enumeration Date:2012-08-21
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV66001363L00000X
KY3007628363LF0000X
AZAP10652363LP2300X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ204924Medicaid
KY7100218950Medicaid
WV3810025120Medicaid
OH0072341Medicaid