Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 176B00000X | Midwife |
NPI | 1013386374 |
---|---|
Provider Name | Marianne Jackson |
First Address | Las Vegas, NV 89144-5405 |
Second Address | Las Vegas, NV 89144-5405 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/09/2015 |
Last Update Date | 16/09/2015 |