MEDICARE: KRYSTAL LONEA JACKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor		NV

General Provider Information

NPI Number	:	1407279326
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRYSTAL LONEA JACKSON

Provider Business Mailing Address
First Line	:	1840 N DECATUR BLVD UNIT 204
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-2269
Country	:	US
Telephone Number	:	331-222-1181
Fax Number	:

Provider Business Practice Location Address
First Line	:	5005 LOSEE RD APT 1031
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89081-2490
Country	:	US
Telephone Number	:	702-624-6618
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/28/2014
Last Update Date	:	01/28/2014

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Directions to “ KRYSTAL LONEA JACKSON ” Practice Location

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