MEDICARE: MS. DEBBIE ANN JACKSON MFT-I

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	01486-L	NV
2	106H00000X	Marriage & Family Therapist	M10274	NV

General Provider Information

NPI Number	:	1972842078
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DEBBIE ANN JACKSON MFT-I

Provider Business Mailing Address
First Line	:	2840 SHAYLA BAY AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89086-1431
Country	:	US
Telephone Number	:	702-884-0405
Fax Number	:

Provider Business Practice Location Address
First Line	:	6765 W CHARLESTON BLVD
Second Line	:	STE. #110
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-2003
Country	:	US
Telephone Number	:	702-884-0405
Fax Number	:

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

Provider Enumeration Date	:	02/08/2013
Last Update Date	:	02/08/2013

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