Provider Demographics
NPI:1427258706
Name:JACKRABBIT FAMILY MEDICINE INC
Entity type:Organization
Organization Name:JACKRABBIT FAMILY MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GABRIELLE
Authorized Official - Middle Name:JULIE
Authorized Official - Last Name:GOODRICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-279-2337
Mailing Address - Street 1:4141 N 32ND ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-4775
Mailing Address - Country:US
Mailing Address - Phone:602-279-2337
Mailing Address - Fax:602-448-8321
Practice Address - Street 1:4141 N 32ND ST
Practice Address - Street 2:SUITE 105
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-4775
Practice Address - Country:US
Practice Address - Phone:602-279-2337
Practice Address - Fax:602-448-8321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-24
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ22811261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ65736Medicare PIN
AZG27379Medicare UPIN