Provider Demographics
NPI:1992107916
Name:JACKSON, SHELON
Entity type:Individual
Prefix:
First Name:SHELON
Middle Name:
Last Name:JACKSON
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 1:2815 W FORD AVE
Mailing Address - Street 2:#1175
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89123-6664
Mailing Address - Country:US
Mailing Address - Phone:702-418-6472
Mailing Address - Fax:
Practice Address - Street 1:2815 W FORD AVE
Practice Address - Street 2:#1175
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89123-6664
Practice Address - Country:US
Practice Address - Phone:702-418-6472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-22
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
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