Provider Demographics
NPI:1043556087
Name:JACKSON, ANTOINETTE S
Entity Type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:S
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 1:3840 N COMMERCE ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032-8104
Mailing Address - Country:US
Mailing Address - Phone:702-649-5995
Mailing Address - Fax:702-399-9801
Practice Address - Street 1:5000 W OAKEY BLVD STE A3-4
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-0391
Practice Address - Country:US
Practice Address - Phone:702-377-1198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-19
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225C00000X
NV14041232543747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor