Provider Demographics
NPI:1386169993
Name:PASTORES, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PASTORES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 N PASADENA UNIT 44
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-3520
Mailing Address - Country:US
Mailing Address - Phone:256-658-8716
Mailing Address - Fax:
Practice Address - Street 1:2225 W SOUTHERN AVE STE B
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-4716
Practice Address - Country:US
Practice Address - Phone:623-888-3502
Practice Address - Fax:480-795-6161
Is Sole Proprietor?:No
Enumeration Date:2017-08-04
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3353235Z00000X
MD07895235Z00000X
AZ12369235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist