Healthcare Provider Details

I. General information

NPI: 1093640989
Provider Name (Legal Business Name): JACKSON MEDICAL ENTERPRISES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8905 W POST RD STE 110
LAS VEGAS NV
89148-2429
US

IV. Provider business mailing address

5055 S FORT APACHE RD UNIT 280
LAS VEGAS NV
89148-1558
US

V. Phone/Fax

Practice location:
  • Phone: 313-461-6194
  • Fax:
Mailing address:
  • Phone: 313-461-6194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DENNIS NATHANIEL JACKSON
Title or Position: OWNER
Credential: M.D.
Phone: 313-461-6194