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General NPI Number Information
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NPI Number | 1386937183
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Entity Type | Individual
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Provider Name | CHARLES LEE JACKSON JR. PTA
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Gender | Male
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Dates
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Enumeration Date | 05/26/2011
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Last Update Date | 05/26/2011
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Provider Practice Location Address
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Address Line | 2250 E FLAMINGO RD
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City | LAS VEGAS
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State | NV
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Zip | 89119-5170
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Country | US
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Telephone | 702-784-4303
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Fax | 702-892-0237
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Provider Business Mailing Address
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Address Line | 2905 PORTADA AVE
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City | HENDERSON
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State | NV
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Zip | 89074-2845
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Country | US
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Telephone | 702-635-6033
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 2012
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License Number State | NV
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