Basic Information
| Provider Information | |||||||||
| NPI: | 1720336910 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DERASIN | ||||||||
| FirstName: | JETTA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3033 N CENTRAL AVE STE 145 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235833001 | ||||||||
| FaxNumber: | 6239746721 | ||||||||
| Practice Location | |||||||||
| Address1: | 1705 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778095092 | ||||||||
| FaxNumber: | 4807189477 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2012 | ||||||||
| LastUpdateDate: | 01/29/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 66001 | WV | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 3007628 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP2300X | AP10652 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 207QA0401X | AP10652 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7100218950 | 05 | KY | MEDICAID | 3810025120 | 05 | WV | MEDICAID | 0072341 | 05 | OH | MEDICAID | 204924 | 05 | AZ | MEDICAID |