Healthcare Provider Details

I. General information

NPI: 1396225736
Provider Name (Legal Business Name): DESTINY SHARAD JACKSON-HALEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2018
Last Update Date: 08/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1024 W OWENS AVE
LAS VEGAS NV
89106-2520
US

IV. Provider business mailing address

1024 W OWENS AVE
LAS VEGAS NV
89106-2520
US

V. Phone/Fax

Practice location:
  • Phone: 702-877-9850
  • Fax:
Mailing address:
  • Phone: 702-877-9850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: