Healthcare Provider Details

I. General information

NPI: 1811285406
Provider Name (Legal Business Name): ERIN M JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2011
Last Update Date: 07/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 GALLETTI WAY BLDG. 8B, 8C
SPARKS NV
89431-5564
US

IV. Provider business mailing address

4865 PRADERA ST
SPARKS NV
89436-0676
US

V. Phone/Fax

Practice location:
  • Phone: 775-324-1490
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number0801286001
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: