MEDICARE: JACKIE JOHNSON

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

General Provider Information

NPI Number	:	1740692318
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKIE JOHNSON

Provider Business Mailing Address
First Line	:	3050 N JONES BLVD
Second Line	:	APT2101
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-6551
Country	:	US
Telephone Number	:	702-561-0432
Fax Number	:

Provider Business Practice Location Address
First Line	:	2605 RAINBOW GLOW ST
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89030-3709
Country	:	US
Telephone Number	:	702-630-5009
Fax Number	:	702-631-9821

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

Provider Enumeration Date	:	05/29/2014
Last Update Date	:	05/29/2014

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Directions to “ JACKIE JOHNSON ” Practice Location

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