Provider Demographics
NPI:1396253258
Name:JACKSON, MICHELLE LARAY (CPC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LARAY
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6202 FLAMING ARROW RD
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-1646
Mailing Address - Country:US
Mailing Address - Phone:812-306-7795
Mailing Address - Fax:
Practice Address - Street 1:6202 FLAMING ARROW RD
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-1646
Practice Address - Country:US
Practice Address - Phone:812-306-7795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-12
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional