Provider Demographics
NPI:1437588225
Name:GARRETT-MABON, JENNIFER LYNN
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:LYNN
Last Name:GARRETT-MABON
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 1:4701 E SAHARA AVE
Mailing Address - Street 2:APT 232
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89104-6300
Mailing Address - Country:US
Mailing Address - Phone:702-748-4121
Mailing Address - Fax:
Practice Address - Street 1:4701 E SAHARA AVE
Practice Address - Street 2:APT 232
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-6300
Practice Address - Country:US
Practice Address - Phone:702-748-4121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-02
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NV225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner