Provider Demographics
NPI:1255682480
Name:HAMPTON, JALISA
Entity Type:Individual
Prefix:
First Name:JALISA
Middle Name:
Last Name:HAMPTON
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 1:2200 N TORREY PINES DR APT 2018
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-6506
Mailing Address - Country:US
Mailing Address - Phone:702-619-1174
Mailing Address - Fax:
Practice Address - Street 1:2200 N TORREY PINES DR APT 2018
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89108-6506
Practice Address - Country:US
Practice Address - Phone:702-619-1174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-27
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1255682480Medicaid