Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225C00000X | Rehabilitation Counselor | NV |
NPI | 1083994982 |
---|---|
Provider Name | Antonio Jackson |
First Address | North Las Vegas, NV 89032-8104 |
Second Address | North Las Vegas, NV 89032-8104 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/08/2011 |
Last Update Date | 23/08/2011 |