Healthcare Provider Details

I. General information

NPI: 1710260559
Provider Name (Legal Business Name): JENNIFER MILITELLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER UNDERHILL

II. Dates (important events)

Enumeration Date: 09/27/2011
Last Update Date: 03/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4285 N RANCHO DR STE 130
LAS VEGAS NV
89130-3455
US

IV. Provider business mailing address

4285 N RANCHO DR STE 130
LAS VEGAS NV
89130-3455
US

V. Phone/Fax

Practice location:
  • Phone: 702-385-5331
  • Fax:
Mailing address:
  • Phone: 702-385-5331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: