Provider Demographics
NPI:1003166604
Name:BERRY, JAMELLE
Entity Type:Individual
Prefix:
First Name:JAMELLE
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JAMELLE
Other - Middle Name:
Other - Last Name:THORNTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2441 TECH CENTER CT STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-0804
Mailing Address - Country:US
Mailing Address - Phone:702-907-6384
Mailing Address - Fax:
Practice Address - Street 1:2441 TECH CENTER CT STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0804
Practice Address - Country:US
Practice Address - Phone:702-907-6384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-12
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
NV2657106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner