MEDICARE: CANNELL 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	225400000X	Rehabilitation Practitioner

General Provider Information

NPI Number	:	1740730118
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CANNELL JACKSON

Provider Business Mailing Address
First Line	:	2725 W. WIGWAM AVE #2009
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89123
Country	:	US
Telephone Number	:	773-844-6231
Fax Number	:

Provider Business Practice Location Address
First Line	:	2725 W. WIGWAM AVE #2009
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89123
Country	:	US
Telephone Number	:	773-844-6231
Fax Number	:

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

Provider Enumeration Date	:	10/10/2016
Last Update Date	:	11/02/2016

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