MEDICARE: MARIANNE JACKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	54302	NV
2	176B00000X	Midwife

General Provider Information

NPI Number	:	1013386374
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIANNE JACKSON

Provider Business Mailing Address
First Line	:	1613 STONEFIELD ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89144-5405
Country	:	US
Telephone Number	:	702-245-6290
Fax Number	:

Provider Business Practice Location Address
First Line	:	1613 STONEFIELD ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89144-5405
Country	:	US
Telephone Number	:	702-245-6290
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2015
Last Update Date	:	09/16/2015

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Directions to “ MARIANNE JACKSON ” Practice Location

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