Provider Demographics
NPI:1215455324
Name:HERNANDEZ, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2350 S JONES BLVD STE 206B
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-3103
Mailing Address - Country:US
Mailing Address - Phone:702-502-8021
Mailing Address - Fax:
Practice Address - Street 1:2350 S JONES BLVD STE 206B
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-3103
Practice Address - Country:US
Practice Address - Phone:702-502-8021
Practice Address - Fax:702-502-8021
Is Sole Proprietor?:No
Enumeration Date:2017-09-08
Last Update Date:2017-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRBT-17-34485106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician