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NPI Code Detail

MEDICARE: BRANDON LEROY JACKSON P.T.

MEDICARE: BRANDON LEROY 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

General Provider Information

NPI Number : 1952340671
Entity Type Code : Individual
Provider Name (Legal Business Name) : BRANDON LEROY 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 :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/06/2006
Last Update Date : 12/21/2021

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