Healthcare Provider Details

I. General information

NPI: 1760344006
Provider Name (Legal Business Name): JENNIFER KOTH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2025
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2225 E FLAMINGO RD STE 202
LAS VEGAS NV
89119-5127
US

IV. Provider business mailing address

2225 E FLAMINGO RD STE 202
LAS VEGAS NV
89119-5127
US

V. Phone/Fax

Practice location:
  • Phone: 702-462-0969
  • Fax:
Mailing address:
  • Phone: 702-462-0969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberCHW1-6332
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: