MEDICARE: DRAKE EDWARD 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	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1770908311
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DRAKE EDWARD JACKSON

Provider Business Mailing Address
First Line	:	9400 BERMUDA RD APT 379
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89123-4420
Country	:	US
Telephone Number	:	323-681-5278
Fax Number	:

Provider Business Practice Location Address
First Line	:	9400 S. BERMUDA RD. APT 379
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89123-4420
Country	:	US
Telephone Number	:	323-681-5278
Fax Number	:

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

Provider Enumeration Date	:	02/19/2014
Last Update Date	:	02/19/2014

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Directions to “ DRAKE EDWARD JACKSON ” Practice Location

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