Basic Information
| Provider Information | |||||||||
| NPI: | 1578993671 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENRY | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROHDE | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2550 N THUNDERBIRD CIR | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852151219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803532235 | ||||||||
| FaxNumber: | 4807760025 | ||||||||
| Practice Location | |||||||||
| Address1: | 4140 LARAMIE ST | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820011969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076376133 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2013 | ||||||||
| LastUpdateDate: | 03/24/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA834 | WY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.