Provider Demographics
NPI:1538926191
Name:TY, JENNIFER JEAN
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:JEAN
Last Name:TY
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 1:2251 N RAMPART BLVD # 165
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-7640
Mailing Address - Country:US
Mailing Address - Phone:917-592-3395
Mailing Address - Fax:
Practice Address - Street 1:2075 PESCARA CT
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89123-3909
Practice Address - Country:US
Practice Address - Phone:917-592-3395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-29
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNVMT.7914225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty