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General NPI Number Information
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NPI Number | 1205266764
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Entity Type | Organization
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Legal Business Name | BRANDON JACKSON PT
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Dates
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Enumeration Date | 11/20/2013
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Last Update Date | 05/02/2014
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Provider Practice Location Address
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Address Line | 4765 S DURANGO DR SUITE 106
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City | LAS VEGAS
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State | NV
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Zip | 89147-8145
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Country | US
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Telephone | 702-898-7633
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Fax | 702-898-6433
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Provider Business Mailing Address
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Address Line | 4765 S DURANGO DR SUITE 106
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City | LAS VEGAS
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State | NV
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Zip | 89147-8145
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Country | US
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Telephone | 702-898-7633
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Fax | 702-898-6433
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Authorized Official
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Title or Position | PHYSICAL THERAPIST
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Name | BRANDON L JACKSON
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Credential | P.T.
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Telephone | 702-845-1386
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251S0007X
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Taxonomy Name | Sports Physical Therapist
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License Number | 1365
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License Number State | NV
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