Healthcare Provider Details

I. General information

NPI: 1487918595
Provider Name (Legal Business Name): JACQUELINE EDWARDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2012
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

356 S MILAN ST
HENDERSON NV
89015-2431
US

IV. Provider business mailing address

848 N RAINBOW BLVD # 493
LAS VEGAS NV
89107-1103
US

V. Phone/Fax

Practice location:
  • Phone: 702-470-3004
  • Fax:
Mailing address:
  • Phone: 702-470-3004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: