Provider Demographics
NPI:1376959163
Name:SIMON, JACCI
Entity Type:Individual
Prefix:
First Name:JACCI
Middle Name:
Last Name:SIMON
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 1:3205 BRADFORD HILL AVE
Mailing Address - Street 2:
Mailing Address - City:N LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-0818
Mailing Address - Country:US
Mailing Address - Phone:702-812-4986
Mailing Address - Fax:
Practice Address - Street 1:3205 BRADFORD HILL AVE
Practice Address - Street 2:
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-0818
Practice Address - Country:US
Practice Address - Phone:702-812-4986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-01
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
NV101YP1600X, 174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No174H00000XOther Service ProvidersHealth Educator