Provider Demographics
NPI:1144069790
Name:PHOENIX RISING TELEPSYCH
Entity type:Organization
Organization Name:PHOENIX RISING TELEPSYCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCINTYRE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:913-398-2530
Mailing Address - Street 1:PO BOX 8544
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE VILLAGE
Mailing Address - State:KS
Mailing Address - Zip Code:66208-0544
Mailing Address - Country:US
Mailing Address - Phone:913-398-2530
Mailing Address - Fax:
Practice Address - Street 1:6917 TOMAHAWK RD
Practice Address - Street 2:
Practice Address - City:PRAIRIE VILLAGE
Practice Address - State:KS
Practice Address - Zip Code:66208-2618
Practice Address - Country:US
Practice Address - Phone:913-398-2530
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-22
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty