Provider Demographics
NPI:1225314404
Name:JACKSON, MARY ELIZABETH (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELIZABETH
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3013 N RANCHO DR
Mailing Address - Street 2:128
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-3345
Mailing Address - Country:US
Mailing Address - Phone:702-272-2222
Mailing Address - Fax:702-272-2221
Practice Address - Street 1:3013 N RANCHO DR
Practice Address - Street 2:128
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-3345
Practice Address - Country:US
Practice Address - Phone:702-272-2222
Practice Address - Fax:702-272-2221
Is Sole Proprietor?:No
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV5450C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical