Provider Demographics
NPI:1710388178
Name:MASON, JERRY
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:MASON
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 1:5135 CAMINO AL NORTE
Mailing Address - Street 2:STE.251
Mailing Address - City:N LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-2387
Mailing Address - Country:US
Mailing Address - Phone:702-813-5413
Mailing Address - Fax:702-853-6722
Practice Address - Street 1:5135 CAMINO AL NORTE
Practice Address - Street 2:250
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-2387
Practice Address - Country:US
Practice Address - Phone:702-813-5413
Practice Address - Fax:702-853-6722
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-04
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty