Healthcare Provider Details

I. General information

NPI: 1275010399
Provider Name (Legal Business Name): JESSICA ROSE BRAVE HEART MS, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2018
Last Update Date: 08/08/2026
Certification Date: 08/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 W DEER SPRINGS WAY
NORTH LAS VEGAS NV
89084-1340
US

IV. Provider business mailing address

5005 LOSEE RD
NORTH LAS VEGAS NV
89081-2479
US

V. Phone/Fax

Practice location:
  • Phone: 605-899-2863
  • Fax:
Mailing address:
  • Phone: 605-899-2863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT0506788
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: