Basic Information
| Provider Information | |||||||||
| NPI: | 1609120351 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ABOULHOSN | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ODEGAARD | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 5924 | ||||||||
| Address2: | 7208 E. CAVE CREEK RD | ||||||||
| City: | CAREFREE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853775924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804889095 | ||||||||
| FaxNumber: | 4804882862 | ||||||||
| Practice Location | |||||||||
| Address1: | 7208 E. CAVE CREEK ROAD | ||||||||
| Address2: | SUITE H | ||||||||
| City: | CAREFREE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804889095 | ||||||||
| FaxNumber: | 4804882862 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2012 | ||||||||
| LastUpdateDate: | 11/02/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | 10062 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No ID Information.