MEDICARE: JACKSON PSYCHIATRIC AND PRIMARY CARE SERVICES

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	363LF0000X	Family Nurse Practitioner
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1689251183
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSON PSYCHIATRIC AND PRIMARY CARE SERVICES

Provider Business Mailing Address
First Line	:	9605 PRESTON HILL ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89178-9384
Country	:	US
Telephone Number	:	901-283-1975
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 CONVENTION CENTER DR STE 900
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89109-2039
Country	:	US
Telephone Number	:	702-355-8294
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	SIMONE JACKSON
Credential	:	APRN, PMHNP-BC
Telephone Number	:	901-283-1975

Provider Enumeration Date	:	03/29/2021
Last Update Date	:	01/29/2026

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