Healthcare Provider Details

I. General information

NPI: 1134644396
Provider Name (Legal Business Name): SIMONE JACKSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SIMONE JACKSON FNP, PMHNP

II. Dates (important events)

Enumeration Date: 08/09/2017
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 CONVENTION CENTER DR STE 900
LAS VEGAS NV
89109-2039
US

IV. Provider business mailing address

9005 W OQUENDO RD APT 3036
LAS VEGAS NV
89148-1524
US

V. Phone/Fax

Practice location:
  • Phone: 702-355-8294
  • Fax:
Mailing address:
  • Phone: 901-283-1975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN002716
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN002716
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP134295
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: