MEDICARE: JERICKA STEWART

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255966933
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERICKA STEWART

Provider Business Mailing Address
First Line	:	2755 E DESERT INN RD STE 180
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-3694
Country	:	US
Telephone Number	:	702-986-3164
Fax Number	:

Provider Business Practice Location Address
First Line	:	2191 PINETOP LN UNIT 102
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-7818
Country	:	US
Telephone Number	:	702-986-3164
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/03/2020
Last Update Date	:	03/03/2020

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Directions to “ JERICKA STEWART ” Practice Location

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