Provider Demographics
NPI:1275118374
Name:CRADDOCK, JERI NICOLE
Entity Type:Individual
Prefix:
First Name:JERI
Middle Name:NICOLE
Last Name:CRADDOCK
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 1:951 LAS PALMAS ENTRADA AVE APT 1728
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89012-5625
Mailing Address - Country:US
Mailing Address - Phone:910-354-5792
Mailing Address - Fax:
Practice Address - Street 1:3101 W CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1931
Practice Address - Country:US
Practice Address - Phone:702-831-6670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRBT-18-67371106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician