Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103TR0400X | Rehabilitation Psychologist | ||
Y | 225400000X | Rehabilitation Practitioner |
NPI | 1720361652 |
---|---|
Provider Name | Marcus Jackson |
First Address | North Las Vegas, NV 89030-3809 |
Second Address | North Las Vegas, NV 89030-3809 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/09/2011 |
Last Update Date | 27/09/2011 |