Healthcare Provider Details

I. General information

NPI: 1407364169
Provider Name (Legal Business Name): MRS. DOROTHY JEAN JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2018
Last Update Date: 01/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5151 MARGO DR
LAS VEGAS NV
89122-6627
US

IV. Provider business mailing address

5151 MARGO DR
LAS VEGAS NV
89122-6627
US

V. Phone/Fax

Practice location:
  • Phone: 702-286-7041
  • Fax:
Mailing address:
  • Phone: 702-286-7041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License NumberNV20141173960
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: