Basic Information
| Provider Information | |||||||||
| NPI: | 1851763635 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANDERWILP | ||||||||
| FirstName: | JESSICA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3030 N CENTRAL AVE STE 1001 | ||||||||
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| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024064786 | ||||||||
| FaxNumber: | 9166364358 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 W THOMAS RD STE 600 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850134221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024061140 | ||||||||
| FaxNumber: | 6024061149 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2015 | ||||||||
| LastUpdateDate: | 07/26/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 6251 | AZ | N | Allopathic & Osteopathic Physicians | Family Medicine | 363AM0700X | 6251 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.