Provider Demographics
NPI:1679910939
Name:IVORY, JARREAU LAMARR
Entity Type:Individual
Prefix:
First Name:JARREAU
Middle Name:LAMARR
Last Name:IVORY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1344 N HOLLYWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89110-2026
Mailing Address - Country:US
Mailing Address - Phone:702-738-6998
Mailing Address - Fax:
Practice Address - Street 1:1344 N HOLLYWOOD BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89110-2026
Practice Address - Country:US
Practice Address - Phone:702-738-6998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-28
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst