Provider Demographics
NPI:1831522358
Name:BAILEY, JONATHAN SHELLEY
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:SHELLEY
Last Name:BAILEY
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 1:9550 W SAHARA AVE
Mailing Address - Street 2:1071
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-5373
Mailing Address - Country:US
Mailing Address - Phone:315-209-0047
Mailing Address - Fax:
Practice Address - Street 1:9550 W SAHARA AVE
Practice Address - Street 2:1071
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-5373
Practice Address - Country:US
Practice Address - Phone:315-209-0047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-20
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV$$$$$$$$$Medicaid