Healthcare Provider Details

I. General information

NPI: 1043186463
Provider Name (Legal Business Name): ST ROSE PSYCHIATRY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2025
Last Update Date: 07/03/2026
Certification Date: 07/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8475 S EASTERN AVE STE 202
LAS VEGAS NV
89123-2863
US

IV. Provider business mailing address

8475 S EASTERN AVE STE 202
LAS VEGAS NV
89123-2863
US

V. Phone/Fax

Practice location:
  • Phone: 775-900-8475
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: JACOB MANJOORAN
Title or Position: OWNER
Credential: MD
Phone: 775-900-8475