MEDICARE: MATTHEW CURTIS JACKSON JR.

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	372600000X	Adult Companion		NV

General Provider Information

NPI Number	:	1558025098
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW CURTIS JACKSON JR.

Provider Business Mailing Address
First Line	:	6170 BOULDER HWY APT 1006
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89122-7705
Country	:	US
Telephone Number	:	909-433-0060
Fax Number	:

Provider Business Practice Location Address
First Line	:	1155 E TWAIN AVE STE 108
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89169-4216
Country	:	US
Telephone Number	:	209-204-5672
Fax Number	:

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

Provider Enumeration Date	:	10/29/2021
Last Update Date	:	10/29/2021

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