=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508219387
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSE JAY JONES L.M.T.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2016
-----------------------------------------------------
Last Update Date | 07/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8751 W CHARLESTON BLVD SUITE 190
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89117-5480
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-408-8479
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3324 VENTANA HILLS DR
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89117-0201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-408-8479
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | NVMT.5419
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------