Provider Demographics
NPI:1134644396
Name:JACKSON, SIMONE (NP)
Entity Type:Individual
Prefix:
First Name:SIMONE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SIMONE
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP
Mailing Address - Street 1:9005 W OQUENDO RD APT 3036
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-1524
Mailing Address - Country:US
Mailing Address - Phone:901-283-1975
Mailing Address - Fax:
Practice Address - Street 1:9029 S PECOS RD STE 2800
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-7199
Practice Address - Country:US
Practice Address - Phone:901-283-1975
Practice Address - Fax:901-283-1975
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-09
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP134295363LF0000X
NVAPRN002716363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health