Healthcare Provider Details

I. General information

NPI: 1104640697
Provider Name (Legal Business Name): JENNER TATZ LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2024
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5426 VEGAS DR
LAS VEGAS NV
89108-2403
US

IV. Provider business mailing address

5426 VEGAS DR
LAS VEGAS NV
89108-2403
US

V. Phone/Fax

Practice location:
  • Phone: 702-806-5268
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberIC-2575
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number11884-M
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: