Healthcare Provider Details

I. General information

NPI: 1043979438
Provider Name (Legal Business Name): JONATHAN PAUL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2021
Last Update Date: 08/30/2024
Certification Date: 08/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7425 W AZURE DR STE 140
LAS VEGAS NV
89130-4425
US

IV. Provider business mailing address

4250 ARVILLE ST APT 17
LAS VEGAS NV
89103-3712
US

V. Phone/Fax

Practice location:
  • Phone: 702-515-4009
  • Fax:
Mailing address:
  • Phone: 503-878-0642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP-4062
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: