Healthcare Provider Details

I. General information

NPI: 1841892957
Provider Name (Legal Business Name): MR. CHRISTOPHER PAUL JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2020
Last Update Date: 11/12/2020
Certification Date: 11/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3708 GILMORE CREEK ST
LAS VEGAS NV
89129-7906
US

IV. Provider business mailing address

3708 GILMORE CREEK ST
LAS VEGAS NV
89129-7906
US

V. Phone/Fax

Practice location:
  • Phone: 702-373-2354
  • Fax:
Mailing address:
  • Phone: 702-373-2354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number88784
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: