Provider Demographics
NPI:1033461280
Name:JACKSON, KEITH DARNELL
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:DARNELL
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4790 PENCARROW CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-2372
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7550 CONSTANTINOPLE AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89129-6505
Practice Address - Country:US
Practice Address - Phone:702-349-4042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-12
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst