Provider Demographics
NPI:1043572035
Name:JACKSON, JOHN FERNDALE
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:FERNDALE
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 1:931 AZURE HEIGHTS PLACE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89110
Mailing Address - Country:US
Mailing Address - Phone:702-505-3753
Mailing Address - Fax:
Practice Address - Street 1:931 AZURE HEIGHTS PLACE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89110
Practice Address - Country:US
Practice Address - Phone:702-505-3753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-14
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst