MEDICARE: ANTUAN 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

General Provider Information

NPI Number	:	1457892838
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTUAN JACKSON

Provider Business Mailing Address
First Line	:	2920 S JONES BLVD
Second Line	:	110B
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-5642
Country	:	US
Telephone Number	:	702-968-9372
Fax Number	:	702-932-3189

Provider Business Practice Location Address
First Line	:	2920 S JONES BLVD
Second Line	:	110B
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-5642
Country	:	US
Telephone Number	:	702-968-9372
Fax Number	:	702-932-3189

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

Provider Enumeration Date	:	03/17/2017
Last Update Date	:	03/17/2017

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