Healthcare Provider Details

I. General information

NPI: 1023359361
Provider Name (Legal Business Name): CAROLE ANNE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2013
Last Update Date: 03/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 HELEN AVE
N LAS VEGAS NV
89030-3721
US

IV. Provider business mailing address

345 PLUM HORSE AVE
N LAS VEGAS NV
89031-1317
US

V. Phone/Fax

Practice location:
  • Phone: 702-275-9838
  • Fax:
Mailing address:
  • Phone: 702-205-6717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: