MEDICARE: RITA 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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1043695158
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RITA JACKSON

Provider Business Mailing Address
First Line	:	4476 PUREZA AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89115-2415
Country	:	US
Telephone Number	:	702-749-6332
Fax Number	:	702-749-6334

Provider Business Practice Location Address
First Line	:	4476 PUREZA AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89115-2415
Country	:	US
Telephone Number	:	702-749-6332
Fax Number	:	702-749-6334

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

Provider Enumeration Date	:	07/30/2015
Last Update Date	:	07/30/2015

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Directions to “ RITA JACKSON ” Practice Location

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