Provider Demographics
NPI:1093475501
Name:JACKSON, WILBUR JR
Entity Type:Individual
Prefix:MR
First Name:WILBUR
Middle Name:
Last Name:JACKSON
Suffix:JR
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 1:1901 HAREN DR APT 321
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89011-4424
Mailing Address - Country:US
Mailing Address - Phone:725-225-8262
Mailing Address - Fax:
Practice Address - Street 1:1901 HAREN DR APT 321
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89011-4424
Practice Address - Country:US
Practice Address - Phone:725-225-8262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-23
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care