Provider Demographics
NPI:1659677870
Name:MOBILE MENTAL HEALTH
Entity Type:Organization
Organization Name:MOBILE MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INDEPENDENT CONTRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:ILLYAS
Authorized Official - Middle Name:MALIK
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:BS,QMHA
Authorized Official - Phone:702-462-3604
Mailing Address - Street 1:736 HILL SHINE AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-2394
Mailing Address - Country:US
Mailing Address - Phone:702-462-3604
Mailing Address - Fax:
Practice Address - Street 1:736 HILL SHINE AVE
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-2394
Practice Address - Country:US
Practice Address - Phone:702-462-3604
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-05
Last Update Date:2011-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness