MEDICARE: MR. ANDREW JACKSON MOTR/L

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	282NR1301X	Rural Acute Care Hospital	10241270-4201	UT
2	225X00000X	Occupational Therapist	OT-2211	NV

General Provider Information

NPI Number	:	1285172841
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ANDREW JACKSON MOTR/L

Provider Business Mailing Address
First Line	:	8736 SHADY PINES DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89143-4460
Country	:	US
Telephone Number	:	435-650-7128
Fax Number	:

Provider Business Practice Location Address
First Line	:	8736 SHADY PINES DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89143-4460
Country	:	US
Telephone Number	:	435-650-7128
Fax Number	:

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

Provider Enumeration Date	:	02/03/2017
Last Update Date	:	04/28/2025

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