Healthcare Provider Details

I. General information

NPI: 1023403474
Provider Name (Legal Business Name): YASSI KUO-JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2015
Last Update Date: 04/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4505 S MARYLAND PKWY BOX 452005
LAS VEGAS NV
89154-9900
US

IV. Provider business mailing address

5050 SPRING VALLEY RD
DALLAS TX
75244-3995
US

V. Phone/Fax

Practice location:
  • Phone: 972-367-4845
  • Fax: 972-367-3451
Mailing address:
  • Phone: 972-367-4845
  • Fax: 972-367-3451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: