Healthcare Provider Details

I. General information

NPI: 1760740773
Provider Name (Legal Business Name): JARED SHOEMAKER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2012
Last Update Date: 07/11/2025
Certification Date: 07/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 DARK CREEK AVE
LAS VEGAS NV
89183-5654
US

IV. Provider business mailing address

84 DARK CREEK AVE
LAS VEGAS NV
89183-5654
US

V. Phone/Fax

Practice location:
  • Phone: 702-319-1555
  • Fax: 702-876-2269
Mailing address:
  • Phone: 702-319-1555
  • Fax: 725-205-2895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: