Provider Demographics
NPI:1174863112
Name:PREWITT, JENNA BROOKE (PA-C)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:BROOKE
Last Name:PREWITT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:BROOKE
Other - Last Name:KAITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:8408 E SAGE DR
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85250-6740
Mailing Address - Country:US
Mailing Address - Phone:480-827-5500
Mailing Address - Fax:
Practice Address - Street 1:1950 S COUNTRY CLUB DR STE 101
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-6044
Practice Address - Country:US
Practice Address - Phone:480-827-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-28
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5351363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical