Provider Demographics
NPI:1447056494
Name:PONCE, BRIANNA JAZYLN
Entity type:Individual
Prefix:
First Name:BRIANNA
Middle Name:JAZYLN
Last Name:PONCE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 DAWN DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89110-2434
Mailing Address - Country:US
Mailing Address - Phone:702-542-5242
Mailing Address - Fax:
Practice Address - Street 1:3660 N RANCHO DR STE 113
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-3188
Practice Address - Country:US
Practice Address - Phone:702-209-3544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-20
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRBT4970106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician