MEDICARE: JUSTICE EDWARD JACKSON-HALEY

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	374U00000X	Home Health Aide
2	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1366922700
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTICE EDWARD JACKSON-HALEY

Provider Business Mailing Address
First Line	:	1024 W OWENS AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-2520
Country	:	US
Telephone Number	:	702-877-9850
Fax Number	:

Provider Business Practice Location Address
First Line	:	1024 W OWENS AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-2520
Country	:	US
Telephone Number	:	702-877-9850
Fax Number	:

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

Provider Enumeration Date	:	08/15/2018
Last Update Date	:	08/15/2018

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Directions to “ JUSTICE EDWARD JACKSON-HALEY ” Practice Location

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