MEDICARE: MRS. LATISHA EVETTE JACKSON BS

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	101YM0800X	Mental Health Counselor		NV

General Provider Information

NPI Number	:	1487912580
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LATISHA EVETTE JACKSON BS

Provider Business Mailing Address
First Line	:	4417 OASIS PLAINS AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89085-2334
Country	:	US
Telephone Number	:	702-688-1470
Fax Number	:	702-688-1470

Provider Business Practice Location Address
First Line	:	4417 OASIS PLAINS AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89085-2334
Country	:	US
Telephone Number	:	702-688-1470
Fax Number	:	702-688-1470

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

Provider Enumeration Date	:	04/25/2012
Last Update Date	:	04/25/2012

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