Basic Information
| Provider Information | |||||||||
| NPI: | 1932682598 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLAIR | ||||||||
| FirstName: | JENA | ||||||||
| MiddleName: | DENNELLE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MFT-INTERN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DREW | ||||||||
| OtherFirstName: | JENA | ||||||||
| OtherMiddleName: | DENNELLE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1200 ROLAND CT | ||||||||
| Address2: | |||||||||
| City: | FERNLEY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 894086604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7752301162 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 860 TYLER WAY | ||||||||
| Address2: | |||||||||
| City: | SPARKS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 894312172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7753560371 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2018 | ||||||||
| LastUpdateDate: | 09/10/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.