Healthcare Provider Details

I. General information

NPI: 1235236308
Provider Name (Legal Business Name): DAVID NEAL JACKSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 04/23/2021
Certification Date: 04/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707 W CHARLESTON BLVD #120
LAS VEGAS NV
89102-2351
US

IV. Provider business mailing address

1701 W CHARLESTON BLVD #215
LAS VEGAS NV
89102-2325
US

V. Phone/Fax

Practice location:
  • Phone: 702-671-5140
  • Fax: 702-385-2745
Mailing address:
  • Phone: 702-968-4347
  • Fax: 702-382-5388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number01065052A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number8687
License Number StateMT
# 3
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number12911
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: