MEDICARE: DEMETIA ENCARNACION JACKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	372500000X	Chore Provider
2	372600000X	Adult Companion
3	3747P1801X	Personal Care Attendant
4	3747A0650X	Attendant Care Provider
5	376J00000X	Homemaker

General Provider Information

NPI Number	:	1609376516
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEMETIA ENCARNACION JACKSON

Provider Business Mailing Address
First Line	:	7320 SMOKE RANCH RD STE H
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-0259
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3050 N JONES BLVD APT 2070
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-6559
Country	:	US
Telephone Number	:	702-955-0575
Fax Number	:

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

Provider Enumeration Date	:	02/16/2018
Last Update Date	:	02/16/2018

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