MEDICARE: MRS. JARDANE KATELLE'-MARIE' ALEXIS B.A.

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	101Y00000X	Counselor		NV

General Provider Information

NPI Number	:	1558857375
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JARDANE KATELLE'-MARIE' ALEXIS B.A.

Provider Business Mailing Address
First Line	:	3644 S FORT APACHE RD APT 2071
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89147-3416
Country	:	US
Telephone Number	:	757-572-4261
Fax Number	:

Provider Business Practice Location Address
First Line	:	3644 S FORT APACHE RD APT 2071
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89147-3416
Country	:	US
Telephone Number	:	757-572-4261
Fax Number	:

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

Provider Enumeration Date	:	07/04/2018
Last Update Date	:	07/04/2018

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