MEDICARE: CODY SCOTT DEJONKER

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	103K00000X	Behavior Analyst	RBT-24372658	NV

General Provider Information

NPI Number	:	1750278891
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CODY SCOTT DEJONKER

Provider Business Mailing Address
First Line	:	2920 S RAINBOW BLVD STE 180
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-6227
Country	:	US
Telephone Number	:	702-600-0099
Fax Number	:	702-602-9393

Provider Business Practice Location Address
First Line	:	2920 S RAINBOW BLVD STE 180
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-6227
Country	:	US
Telephone Number	:	702-600-0099
Fax Number	:	702-602-9393

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

Provider Enumeration Date	:	06/20/2025
Last Update Date	:	06/20/2025

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