Healthcare Provider Details

I. General information

NPI: 1376913111
Provider Name (Legal Business Name): MRS. AMANDA MARIE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AMANDA MAIRE JACKSON AMANDA MARIE SELLARS

II. Dates (important events)

Enumeration Date: 10/06/2015
Last Update Date: 04/02/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 GOLDLEAF FALLS AVE
NORTH LAS VEGAS NV
89031-2957
US

IV. Provider business mailing address

24 GOLDLEAF FALLS AVE
NORTH LAS VEGAS NV
89031-2957
US

V. Phone/Fax

Practice location:
  • Phone: 202-909-5016
  • Fax:
Mailing address:
  • Phone: 202-909-5016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11782-C
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: