MEDICARE: MRS. DOROTHY JEAN 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	261QA0600X	Adult Day Care Clinic/Center	NV20141173960	NV

General Provider Information

NPI Number	:	1407364169
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DOROTHY JEAN JACKSON

Provider Business Mailing Address
First Line	:	5151 MARGO DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89122-6627
Country	:	US
Telephone Number	:	702-286-7041
Fax Number	:

Provider Business Practice Location Address
First Line	:	5151 MARGO DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89122-6627
Country	:	US
Telephone Number	:	702-286-7041
Fax Number	:

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

Provider Enumeration Date	:	01/16/2018
Last Update Date	:	01/16/2018

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