Healthcare Provider Details

I. General information

NPI: 1801436555
Provider Name (Legal Business Name): MS. EVETTE M JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2020
Last Update Date: 01/10/2020
Certification Date: 01/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 HAMMILL LN
RENO NV
89511-1004
US

IV. Provider business mailing address

517 HAMMILL LN
RENO NV
89511-1004
US

V. Phone/Fax

Practice location:
  • Phone: 775-824-2323
  • Fax:
Mailing address:
  • Phone: 775-824-2323
  • Fax: 775-824-2424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: