Provider Demographics
NPI:1306879911
Name:WILLIAM P JACKS MD CHARTERED
Entity type:Organization
Organization Name:WILLIAM P JACKS MD CHARTERED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:P
Authorized Official - Last Name:JACKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-649-9070
Mailing Address - Street 1:2031 MCDANIEL ST STE 250
Mailing Address - Street 2:
Mailing Address - City:N LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89030-6309
Mailing Address - Country:US
Mailing Address - Phone:702-649-9070
Mailing Address - Fax:702-649-9080
Practice Address - Street 1:2031 MCDANIEL ST STE 250
Practice Address - Street 2:
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-6309
Practice Address - Country:US
Practice Address - Phone:702-649-9070
Practice Address - Fax:702-649-9080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV38521Medicare PIN