Healthcare Provider Details

I. General information

NPI: 1083175640
Provider Name (Legal Business Name): JAYLEN JORDAN CTRS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2019
Last Update Date: 11/30/2020
Certification Date: 11/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6900 N PECOS RD
NORTH LAS VEGAS NV
89086-4400
US

IV. Provider business mailing address

10085 MALIBU CREEK CT UNIT 101
LAS VEGAS NV
89183-3955
US

V. Phone/Fax

Practice location:
  • Phone: 702-791-9000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: