Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 176B00000X | Midwife | LM167 | AZ |
NPI | 1154666030 |
---|---|
Provider Name | Jennifer Jay Bass |
First Address | Mesa, AZ 85215-9639 |
Second Address | Mesa, AZ 85215-9639 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/12/2012 |
Last Update Date | 25/04/2014 |