Healthcare Provider Details

I. General information

NPI: 1083994982
Provider Name (Legal Business Name): ANTONIO JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2011
Last Update Date: 08/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3840 N COMMERCE ST STE. 200
NORTH LAS VEGAS NV
89032-8104
US

IV. Provider business mailing address

3840 N COMMERCE ST STE. 200
NORTH LAS VEGAS NV
89032-8104
US

V. Phone/Fax

Practice location:
  • Phone: 702-646-7570
  • Fax:
Mailing address:
  • Phone: 702-646-7570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: