Healthcare Provider Details

I. General information

NPI: 1184915589
Provider Name (Legal Business Name): JESSICA CISNEROS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2011
Last Update Date: 03/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4285 N RANCHO DR STE 160
LAS VEGAS NV
89130-3456
US

IV. Provider business mailing address

4285 N RANCHO DR STE 160
LAS VEGAS NV
89130-3456
US

V. Phone/Fax

Practice location:
  • Phone: 702-685-3459
  • Fax: 702-851-8528
Mailing address:
  • Phone: 702-685-3459
  • Fax: 702-851-8528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: