MEDICARE: JENNIFER DOUGLAS MS, CPC-INTERN

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	101YM0800X	Mental Health Counselor	CI5471	NV

General Provider Information

NPI Number	:	1699596577
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER DOUGLAS MS, CPC-INTERN

Provider Business Mailing Address
First Line	:	3053 W CRAIG RD STE E320
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-5124
Country	:	US
Telephone Number	:	702-301-1925
Fax Number	:

Provider Business Practice Location Address
First Line	:	7433 EGGSHELL DR
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89084-2481
Country	:	US
Telephone Number	:	702-530-5007
Fax Number	:

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

Provider Enumeration Date	:	10/23/2024
Last Update Date	:	10/23/2024

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