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NPI Code Detail

MEDICARE: JEFFERSON DETRICK

MEDICARE: JEFFERSON DETRICK
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
1103K00000XBehavior Analyst

General Provider Information

NPI Number : 1548619505
Entity Type Code : Individual
Provider Name (Legal Business Name) : JEFFERSON DETRICK
Provider Business Mailing Address
First Line : 5021 ALTA DR
Second Line :
City : LAS VEGAS
State : NV
Zip : 89107-3937
Country : US
Telephone Number : 702-816-2595
Fax Number : 702-816-2574
Provider Business Practice Location Address
First Line : 5021 ALTA DR
Second Line :
City : LAS VEGAS
State : NV
Zip : 89107-3937
Country : US
Telephone Number : 702-816-2595
Fax Number : 702-816-2574
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/09/2016
Last Update Date : 06/09/2016

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Directions to “ JEFFERSON DETRICK ” Practice Location

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