MEDICARE: SEVYN 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	310400000X	Assisted Living Facility	NV20243092257	NV

General Provider Information

NPI Number	:	1336988732
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SEVYN JACKSON

Provider Business Mailing Address
First Line	:	4612 CATFISH BEND RD
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89031-4242
Country	:	US
Telephone Number	:	310-216-8074
Fax Number	:

Provider Business Practice Location Address
First Line	:	2033 RIDERWOOD AVE
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89032-0670
Country	:	US
Telephone Number	:	310-216-8074
Fax Number	:

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

Provider Enumeration Date	:	05/23/2024
Last Update Date	:	05/23/2024

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Directions to “ SEVYN JACKSON ” Practice Location

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