=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952112252
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. JAEL ANTHONY EDWARDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2025
-----------------------------------------------------
Last Update Date | 01/03/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 871 CORONADO CENTER DR STE 200
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89052-3977
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-832-6727
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8020 CIMARRON RIDGE DR UNIT 201
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89128-1939
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-265-5607
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106E00000X
-----------------------------------------------------
Taxonomy Name | Assistant Behavior Analyst
-----------------------------------------------------
License Number | LABA457
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------