Healthcare Provider Details

I. General information

NPI: 1174970883
Provider Name (Legal Business Name): SHAILENDRA JAIN CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2016
Last Update Date: 04/29/2025
Certification Date: 04/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6855 W CHARLESTON BLVD STE A
LAS VEGAS NV
89117-1675
US

IV. Provider business mailing address

4310 METRO PKWY STE 205
FORT MYERS FL
33916-9416
US

V. Phone/Fax

Practice location:
  • Phone: 725-205-3557
  • Fax: 866-531-4145
Mailing address:
  • Phone: 239-236-8784
  • Fax: 239-790-2624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN9485699
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number832251
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCOA.19140-NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: