Provider Demographics
NPI:1285172841
Name:JACKSON, ANDREW (MOTR/L)
Entity type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:
Last Name:JACKSON
Suffix:
Gender:
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8736 SHADY PINES DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89143-4460
Mailing Address - Country:US
Mailing Address - Phone:435-650-7128
Mailing Address - Fax:
Practice Address - Street 1:8736 SHADY PINES DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89143-4460
Practice Address - Country:US
Practice Address - Phone:435-650-7128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-03
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10241270-4201282NR1301X
NVOT-2211225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No282NR1301XHospitalsGeneral Acute Care HospitalRural