Healthcare Provider Details

I. General information

NPI: 1801624580
Provider Name (Legal Business Name): JERMAINE M BOWEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2024
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7260 W AZURE DR STE 140-144
LAS VEGAS NV
89130-7999
US

IV. Provider business mailing address

2655 E DEER SPRINGS WAY APT 2166
NORTH LAS VEGAS NV
89086-1471
US

V. Phone/Fax

Practice location:
  • Phone: 702-789-7282
  • Fax:
Mailing address:
  • Phone: 702-357-1184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: