MEDICARE: HANNI HELENA 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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1447874128
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HANNI HELENA JACKSON

Provider Business Mailing Address
First Line	:	777 E QUARTZ AVE # 7012
Second Line	:
City	:	SANDY VALLEY
State	:	NV
Zip	:	89019-8501
Country	:	US
Telephone Number	:	702-723-5388
Fax Number	:	702-723-5389

Provider Business Practice Location Address
First Line	:	777 E QUARTZ AVE UNIT B
Second Line	:
City	:	SANDY VALLEY
State	:	NV
Zip	:	89019-8501
Country	:	US
Telephone Number	:	702-723-5388
Fax Number	:	702-723-5389

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

Provider Enumeration Date	:	05/29/2020
Last Update Date	:	05/29/2020

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