MEDICARE: JEAN FAJARDO ASSOCIATES LLC

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	251S00000X	Community/Behavioral Health Agency	20111195118	NV

General Provider Information

NPI Number	:	1982996534
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JEAN FAJARDO ASSOCIATES LLC

Provider Business Mailing Address
First Line	:	7465 W LAKE MEAD BLVD STE 100
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-1033
Country	:	US
Telephone Number	:	702-343-3459
Fax Number	:	702-343-3459

Provider Business Practice Location Address
First Line	:	7465 W LAKE MEAD BLVD STE 100
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-1033
Country	:	US
Telephone Number	:	702-343-3459
Fax Number	:	702-343-3459

Authorized Official
Title or Position	:	OWNER/MANAGER
Name	:	JEAN PAULA FAJARDO
Credential	:	LCSW
Telephone Number	:	702-343-3459

Provider Enumeration Date	:	05/13/2011
Last Update Date	:	05/13/2011

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