Provider Demographics
NPI:1720336910
Name:VALLE, JETTA (MSN, PMHNP, FNP)
Entity type:Individual
Prefix:MRS
First Name:JETTA
Middle Name:
Last Name:VALLE
Suffix:
Gender:F
Credentials:MSN, PMHNP, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21168 E OCOTILLO RD # 1271
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-8175
Mailing Address - Country:US
Mailing Address - Phone:520-677-8025
Mailing Address - Fax:888-205-9338
Practice Address - Street 1:21168 E OCOTILLO RD # 1271
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-8175
Practice Address - Country:US
Practice Address - Phone:520-677-8025
Practice Address - Fax:888-205-9338
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-21
Last Update Date:2025-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP10652207QA0401X, 363LF0000X, 363LP2300X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ204924Medicaid
KY7100218950Medicaid
WV3810025120Medicaid
OH0072341Medicaid