Provider Demographics
NPI:1164123279
Name:MANDILK, JENNA LYNN (RBT)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:LYNN
Last Name:MANDILK
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1060 WIGWAM PKWY
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-8162
Mailing Address - Country:US
Mailing Address - Phone:702-547-6971
Mailing Address - Fax:702-547-6948
Practice Address - Street 1:3950 LAS VEGAS BLVD N # A2
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89115-0598
Practice Address - Country:US
Practice Address - Phone:702-547-6971
Practice Address - Fax:702-547-6948
Is Sole Proprietor?:No
Enumeration Date:2023-03-15
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NVRBT-23-106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician