Provider Demographics
NPI:1699596577
Name:DOUGLAS, JENNIFER (MS, CPC-INTERN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:MS, CPC-INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3053 W CRAIG RD STE E320
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032-5124
Mailing Address - Country:US
Mailing Address - Phone:702-301-1925
Mailing Address - Fax:
Practice Address - Street 1:7433 EGGSHELL DR
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89084-2481
Practice Address - Country:US
Practice Address - Phone:702-530-5007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-23
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVCI5471101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health