Healthcare Provider Details

I. General information

NPI: 1679481162
Provider Name (Legal Business Name): JOHN JACOBS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2026
Last Update Date: 08/28/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3035 S MARYLAND PKWY
LAS VEGAS NV
89109-2200
US

IV. Provider business mailing address

541 W 3RD ST APT 38
RENO NV
89503-5228
US

V. Phone/Fax

Practice location:
  • Phone: 702-857-8800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: