Provider Demographics
NPI:1861675548
Name:HENDERSON, JAVONNI
Entity Type:Individual
Prefix:
First Name:JAVONNI
Middle Name:
Last Name:HENDERSON
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 1:3209 ORANGE ORCHID PL UNIT 3
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89084-3350
Mailing Address - Country:US
Mailing Address - Phone:510-798-1386
Mailing Address - Fax:
Practice Address - Street 1:1515 E TROPICANA AVE STE 375
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-6520
Practice Address - Country:US
Practice Address - Phone:510-798-1386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-17
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV104100000X, 1041C0700X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty