MEDICARE: JENNA MANDILK-LONGHURST RBT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	RBT-23-263725

General Provider Information

NPI Number	:	1164123279
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNA MANDILK-LONGHURST RBT

Provider Business Mailing Address
First Line	:	1200 CONCORD AVE STE 185
Second Line	:
City	:	CONCORD
State	:	CA
Zip	:	94520-5006
Country	:	US
Telephone Number	:	702-547-6971
Fax Number	:	702-547-6948

Provider Business Practice Location Address
First Line	:	3950 LAS VEGAS BLVD N # A2
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89115-0598
Country	:	US
Telephone Number	:	702-547-6971
Fax Number	:	702-547-6948

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/15/2023
Last Update Date	:	03/23/2026

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Directions to “ JENNA MANDILK-LONGHURST RBT” Practice Location

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