Healthcare Provider Details

I. General information

NPI: 1578927679
Provider Name (Legal Business Name): CHAD JASON TERRY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2016
Last Update Date: 06/05/2023
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6600 W CHARLESTON BLVD STE 142
LAS VEGAS NV
89146-9001
US

IV. Provider business mailing address

3014 W CHARLESTON BLVD STE 130
LAS VEGAS NV
89102-0083
US

V. Phone/Fax

Practice location:
  • Phone: 702-440-8430
  • Fax:
Mailing address:
  • Phone: 480-246-7243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number5101022812
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberDO3037
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: