Healthcare Provider Details

I. General information

NPI: 1619414125
Provider Name (Legal Business Name): JAKE IPSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2017
Last Update Date: 01/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 WILSON CIR
BOULDER CITY NV
89005-4401
US

IV. Provider business mailing address

200 WILSON CIR
BOULDER CITY NV
89005-4401
US

V. Phone/Fax

Practice location:
  • Phone: 702-294-7100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: