MEDICARE: MRS. SEQUOIA 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	172V00000X	Community Health Worker		NV

General Provider Information

NPI Number	:	1316548688
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SEQUOIA JACKSON

Provider Business Mailing Address
First Line	:	5135 CAMINO AL NORTE STE 210
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-2391
Country	:	US
Telephone Number	:	310-951-2985
Fax Number	:

Provider Business Practice Location Address
First Line	:	5135 CAMINO AL NORTE STE 230
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-2391
Country	:	US
Telephone Number	:	702-690-9686
Fax Number	:

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

Provider Enumeration Date	:	11/03/2020
Last Update Date	:	11/03/2020

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