MEDICARE: DEMARCUS 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	103K00000X	Behavior Analyst		NV

General Provider Information

NPI Number	:	1629433750
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEMARCUS JACKSON

Provider Business Mailing Address
First Line	:	2317 CASEY DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-2251
Country	:	US
Telephone Number	:	702-956-5382
Fax Number	:

Provider Business Practice Location Address
First Line	:	2317 CASEY DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-2251
Country	:	US
Telephone Number	:	702-956-5382
Fax Number	:

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

Provider Enumeration Date	:	12/16/2015
Last Update Date	:	12/16/2015

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Directions to “ DEMARCUS JACKSON ” Practice Location

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