Basic Information
| Provider Information | |||||||||
| NPI: | 1548892573 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLLOCK | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LAUREN | ||||||||
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| Credential: | RBT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1060 WIGWAM PKWY | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890748162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7025476971 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5502 S FORT APACHE RD | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891487683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7025476971 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2020 | ||||||||
| LastUpdateDate: | 02/07/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-20-112085 | NV | Y |
No ID Information.