Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TB0200X | Cognitive & Behavioral Psychologist |
NPI | 1144526369 |
---|---|
Provider Name | Miss Shalonda Monique Jackson |
First Address | North Las Vegas, NV 89031-7917 |
Second Address | North Las Vegas, NV 89031-7917 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/02/2011 |
Last Update Date | 04/02/2011 |