Healthcare Provider Details

I. General information

NPI: 1255374716
Provider Name (Legal Business Name): MAX JACKSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 09/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 MILL ST SUITE 100
RENO NV
89502-1413
US

IV. Provider business mailing address

780 KUENZLI ST SUITE 202
RENO NV
89502-1011
US

V. Phone/Fax

Practice location:
  • Phone: 775-982-5000
  • Fax: 775-982-5417
Mailing address:
  • Phone: 775-982-4590
  • Fax: 775-982-4595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR3H65
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number12030
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: