Provider Demographics
NPI:1386937183
Name:JACKSON, CHARLES LEE JR (PTA)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:LEE
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2905 PORTADA AVE
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-2845
Mailing Address - Country:US
Mailing Address - Phone:702-635-6033
Mailing Address - Fax:
Practice Address - Street 1:2250 E FLAMINGO RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-5170
Practice Address - Country:US
Practice Address - Phone:702-784-4303
Practice Address - Fax:702-892-0237
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-26
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2012225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant