MEDICARE: LYDIA 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	3747P1801X	Personal Care Attendant

General Provider Information

NPI Number	:	1417605726
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYDIA JACKSON

Provider Business Mailing Address
First Line	:	410 S RAMPART BLVD STE 390
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89145-5749
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5816 SANTA CATALINA AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-4711
Country	:	US
Telephone Number	:	702-858-1030
Fax Number	:

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

Provider Enumeration Date	:	03/15/2022
Last Update Date	:	03/15/2022

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Directions to “ LYDIA JACKSON ” Practice Location

Language	Start Address	Practice Location

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