Provider Demographics
NPI:1033868989
Name:ENNIS, JAYDEN TREVON
Entity Type:Individual
Prefix:
First Name:JAYDEN
Middle Name:TREVON
Last Name:ENNIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2831 SAINT ROSE PKWY
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-4840
Mailing Address - Country:US
Mailing Address - Phone:702-589-4712
Mailing Address - Fax:888-845-8897
Practice Address - Street 1:2831 SAINT ROSE PKWY
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-4840
Practice Address - Country:US
Practice Address - Phone:702-589-4712
Practice Address - Fax:888-845-8897
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-19
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician