Provider Demographics
NPI:1740011923
Name:NA, JANE (PMHNP)
Entity type:Individual
Prefix:MS
First Name:JANE
Middle Name:
Last Name:NA
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 W GROVE PKWY APT 1083
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-4548
Mailing Address - Country:US
Mailing Address - Phone:602-500-1264
Mailing Address - Fax:
Practice Address - Street 1:401 W BASELINE RD STE 108
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-5349
Practice Address - Country:US
Practice Address - Phone:928-504-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-09
Last Update Date:2024-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ312692363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health