Provider Demographics
NPI:1417596578
Name:FUSCO, JHOANA DELENA
Entity Type:Individual
Prefix:
First Name:JHOANA
Middle Name:DELENA
Last Name:FUSCO
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 1:2715 E RUSSELL RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-2426
Mailing Address - Country:US
Mailing Address - Phone:702-848-1696
Mailing Address - Fax:
Practice Address - Street 1:3926 BROKEN OAK LN
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-0129
Practice Address - Country:US
Practice Address - Phone:941-779-4472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-06
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRBT1021106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty