MEDICARE: CHARLES EDWARD JACKSON JR.

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	103TR0400X	Rehabilitation Psychologist
2	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1457669848
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES EDWARD JACKSON JR.

Provider Business Mailing Address
First Line	:	1407 HEALING WATERS LN
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89031-1803
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1407 HEALING WATER LANE
Second Line	:
City	:	N.LAS VEGAS
State	:	NV
Zip	:	89031
Country	:	US
Telephone Number	:	702-485-0883
Fax Number	:

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

Provider Enumeration Date	:	09/20/2010
Last Update Date	:	09/20/2010

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