MEDICARE: MICHELLE LARAY JACKSON CPC

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	101YP2500X	Professional Counselor		NV

General Provider Information

NPI Number	:	1396253258
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE LARAY JACKSON CPC

Provider Business Mailing Address
First Line	:	6202 FLAMING ARROW RD
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-1646
Country	:	US
Telephone Number	:	812-306-7795
Fax Number	:

Provider Business Practice Location Address
First Line	:	6202 FLAMING ARROW RD
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-1646
Country	:	US
Telephone Number	:	812-306-7795
Fax Number	:

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

Provider Enumeration Date	:	01/12/2018
Last Update Date	:	11/15/2023

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