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NPI Code Detail

MEDICARE: CHARLES LEE JACKSON JR. PTA

MEDICARE: CHARLES LEE JACKSON JR. PTA
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
1225200000XPhysical Therapy Assistant2012NV

General Provider Information

NPI Number : 1386937183
Entity Type Code : Individual
Provider Name (Legal Business Name) : CHARLES LEE JACKSON JR. PTA
Provider Business Mailing Address
First Line : 2905 PORTADA AVE
Second Line :
City : HENDERSON
State : NV
Zip : 89074-2845
Country : US
Telephone Number : 702-635-6033
Fax Number :
Provider Business Practice Location Address
First Line : 2250 E FLAMINGO RD
Second Line :
City : LAS VEGAS
State : NV
Zip : 89119-5170
Country : US
Telephone Number : 702-784-4303
Fax Number : 702-892-0237
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/26/2011
Last Update Date : 05/26/2011

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