Provider Demographics
NPI:1013386374
Name:JACKSON, MARIANNE
Entity Type:Individual
Prefix:
First Name:MARIANNE
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 1:1613 STONEFIELD ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89144-5405
Mailing Address - Country:US
Mailing Address - Phone:702-245-6290
Mailing Address - Fax:
Practice Address - Street 1:1613 STONEFIELD ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89144-5405
Practice Address - Country:US
Practice Address - Phone:702-245-6290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV54302163W00000X
176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No163W00000XNursing Service ProvidersRegistered Nurse