Provider Demographics
NPI:1770008757
Name:TRAVIS, JENNIFER JOHNNAE
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:JOHNNAE
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2421 TECH CENTER CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-0804
Mailing Address - Country:US
Mailing Address - Phone:702-560-1898
Mailing Address - Fax:
Practice Address - Street 1:2421 TECH CENTER CT
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0804
Practice Address - Country:US
Practice Address - Phone:702-560-1898
Practice Address - Fax:702-974-1521
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-10
Last Update Date:2017-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral