Provider Demographics
NPI:1750735163
Name:OLLIS, JACKIE (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:OLLIS
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1351 N ALMA SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-5936
Mailing Address - Country:US
Mailing Address - Phone:480-814-7789
Mailing Address - Fax:
Practice Address - Street 1:625 N PLAZA DR
Practice Address - Street 2:
Practice Address - City:APACHE JUNCTION
Practice Address - State:AZ
Practice Address - Zip Code:85120-5501
Practice Address - Country:US
Practice Address - Phone:480-474-5584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-21
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN197907163W00000X
AZAP8521363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse