Provider Demographics
NPI:1639331630
Name:DAUGHARTHY, JENNIFER LAUREN (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LAUREN
Last Name:DAUGHARTHY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2620 REGATTA DR STE 102
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-6892
Mailing Address - Country:US
Mailing Address - Phone:310-702-5528
Mailing Address - Fax:
Practice Address - Street 1:2620 REGATTA DR STE 102
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-6892
Practice Address - Country:US
Practice Address - Phone:310-702-5528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV13239207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVCS18202OtherPHARMACY/CONTROLLED SUBSTANCE CERTIFICATE
NV13239OtherNV MEDICAL LICENSE
NVFD0620838OtherDEA
NVCS18202OtherPHARMACY/CONTROLLED SUBSTANCE CERTIFICATE