Provider Demographics
NPI:1447508023
Name:JALLO, JENNIFER JANE (PA-C)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:JANE
Last Name:JALLO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 W THOMAS RD #301
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013
Mailing Address - Country:US
Mailing Address - Phone:602-406-7765
Mailing Address - Fax:
Practice Address - Street 1:2910 N 3RD AVE # 330
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4434
Practice Address - Country:US
Practice Address - Phone:602-406-8811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5158363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ733587Medicaid
AZ733587Medicaid