MEDICARE: OCEAN CHALIZA 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	:	1750683876
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OCEAN CHALIZA JACKSON

Provider Business Mailing Address
First Line	:	5067 MADRE MESA DR
Second Line	:	UNIT 2057
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-3535
Country	:	US
Telephone Number	:	424-204-3416
Fax Number	:	800-783-6931

Provider Business Practice Location Address
First Line	:	5067 MADRE MESA DR
Second Line	:	UNIT 2057
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-3535
Country	:	US
Telephone Number	:	424-204-3416
Fax Number	:	800-783-6931

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

Provider Enumeration Date	:	11/22/2010
Last Update Date	:	11/22/2010

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