Provider Demographics
NPI:1912293192
Name:PERRY-KEBEDE, JILL
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:PERRY-KEBEDE
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 1:3937 SPENCER ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-5203
Mailing Address - Country:US
Mailing Address - Phone:702-604-5326
Mailing Address - Fax:
Practice Address - Street 1:7473 W LAKE MEAD BLVD
Practice Address - Street 2:221
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0265
Practice Address - Country:US
Practice Address - Phone:702-562-1248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-25
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Single Specialty