Provider Demographics
NPI:1558857375
Name:ALEXIS, JARDANE KATELLE'-MARIE' (BA)
Entity Type:Individual
Prefix:MRS
First Name:JARDANE
Middle Name:KATELLE'-MARIE'
Last Name:ALEXIS
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3644 S FORT APACHE RD APT 2071
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-3416
Mailing Address - Country:US
Mailing Address - Phone:757-572-4261
Mailing Address - Fax:
Practice Address - Street 1:3644 S FORT APACHE RD APT 2071
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89147-3416
Practice Address - Country:US
Practice Address - Phone:757-572-4261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-04
Last Update Date:2018-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor