Healthcare Provider Details

I. General information

NPI: 1669924908
Provider Name (Legal Business Name): JANA MITCHELL-MOMOH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2016
Last Update Date: 09/04/2023
Certification Date: 09/04/2023
Deactivation Date: 11/15/2017
Reactivation Date: 09/01/2023

III. Provider practice location address

1050 WHITNEY RANCH DR
HENDERSON NV
89014-2540
US

IV. Provider business mailing address

1050 WHITNEY RANCH DR APT 1626
HENDERSON NV
89014-2546
US

V. Phone/Fax

Practice location:
  • Phone: 612-743-7385
  • Fax:
Mailing address:
  • Phone: 127-437-3856
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: