Healthcare Provider Details

I. General information

NPI: 1821376344
Provider Name (Legal Business Name): SHAETONNA MARIE JACKSON MSW-LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2011
Last Update Date: 09/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2820 W CHARLESTON BLVD C23
LAS VEGAS NV
89102-1942
US

IV. Provider business mailing address

995 SIERRA VISTA DR APT. 328
LAS VEGAS NV
89169-9387
US

V. Phone/Fax

Practice location:
  • Phone: 702-437-4673
  • Fax: 702-438-4673
Mailing address:
  • Phone: 765-635-7698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6011-S
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberIC-691
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: