Provider Demographics
NPI:1982979654
Name:JACKSON-ROBERTS, TASHONDRA KIOKA
Entity type:Individual
Prefix:
First Name:TASHONDRA
Middle Name:KIOKA
Last Name:JACKSON-ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 ERVA ST
Mailing Address - Street 2:APT 204-P
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-6300
Mailing Address - Country:US
Mailing Address - Phone:702-285-8884
Mailing Address - Fax:
Practice Address - Street 1:7473 W LAKE MEAD BLVD
Practice Address - Street 2:STE 100
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0265
Practice Address - Country:US
Practice Address - Phone:702-483-7503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-14
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health