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NPI Code Detail

MEDICARE: BRANDON JACKSON, P T

MEDICARE: BRANDON JACKSON, P T
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
1225100000XPhysical Therapist1365NV

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1487682076
Entity Type Code : Organization
Provider Name (Legal Business Name) : BRANDON JACKSON, P T
Provider Business Mailing Address
First Line : 4765 S. DURANGO DR.
Second Line : STE 106
City : LAS VEGAS
State : NV
Zip : 89147
Country : US
Telephone Number : 702-898-7633
Fax Number : 702-898-6433
Provider Business Practice Location Address
First Line : 4765 S. DURANGO DR.
Second Line : STE 106
City : LAS VEGAS
State : NV
Zip : 89147
Country : US
Telephone Number : 702-898-7633
Fax Number : 702-898-6433
Authorized Official
Title or Position : OWNER
Name : MR. BRANDON LEROY JACKSON
Credential : P.T.
Telephone Number : 702-898-7633
Provider Enumeration Date : 06/30/2006
Last Update Date : 08/12/2025

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