Provider Demographics
NPI:1194311134
Name:POWELL-POLLARD, JEROME
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:
Last Name:POWELL-POLLARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8329 FAWN MEADOW AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89149-4513
Mailing Address - Country:US
Mailing Address - Phone:725-251-0750
Mailing Address - Fax:
Practice Address - Street 1:8329 FAWN MEADOW AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89149-4513
Practice Address - Country:US
Practice Address - Phone:725-251-0750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health