Healthcare Provider Details

I. General information

NPI: 1790149151
Provider Name (Legal Business Name): JERISSA PLUMMER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2016
Last Update Date: 04/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4956 DRIFTING PEBBLE ST
NORTH LAS VEGAS NV
89081-3057
US

IV. Provider business mailing address

4956 DRIFTING PEBBLE ST
NORTH LAS VEGAS NV
89081-3057
US

V. Phone/Fax

Practice location:
  • Phone: 608-512-3251
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: