Provider Demographics
NPI:1154842334
Name:JACKSON, ENDEEIA SHREE
Entity Type:Individual
Prefix:
First Name:ENDEEIA
Middle Name:SHREE
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 1:3097 E WARM SPRINGS RD STE 400
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-3757
Mailing Address - Country:US
Mailing Address - Phone:702-850-8700
Mailing Address - Fax:702-850-8707
Practice Address - Street 1:5370 E CRAIG RD APT 2223
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89115-2179
Practice Address - Country:US
Practice Address - Phone:702-771-0091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-28
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1601744335225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner