MEDICARE: EMRIC JAVAN JACKSON RBT

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	RBT3777	NV

General Provider Information

NPI Number	:	1497535520
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMRIC JAVAN JACKSON RBT

Provider Business Mailing Address
First Line	:	5163 INDIAN RIVER DR UNIT 194
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-6142
Country	:	US
Telephone Number	:	678-948-8822
Fax Number	:

Provider Business Practice Location Address
First Line	:	8064 W SAHARA AVE STE 100
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-1998
Country	:	US
Telephone Number	:	702-829-8929
Fax Number	:

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

Provider Enumeration Date	:	10/05/2023
Last Update Date	:	10/05/2023

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Directions to “ EMRIC JAVAN JACKSON RBT” Practice Location

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