Provider Demographics
NPI:1699108613
Name:FACHOLAS, JAMIE ANITA (MA)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:ANITA
Last Name:FACHOLAS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2780 S JONES BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-5625
Mailing Address - Country:US
Mailing Address - Phone:702-820-3061
Mailing Address - Fax:
Practice Address - Street 1:2780 S JONES BLVD STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-5625
Practice Address - Country:US
Practice Address - Phone:702-605-5395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-13
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVCP1150-R101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health