Provider Demographics
NPI:1235236308
Name:JACKSON, DAVID NEAL (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:NEAL
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1701 W CHARLESTON BLVD
Mailing Address - Street 2:#215
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-2325
Mailing Address - Country:US
Mailing Address - Phone:702-968-4347
Mailing Address - Fax:702-382-5388
Practice Address - Street 1:1707 W CHARLESTON BLVD
Practice Address - Street 2:#120
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2351
Practice Address - Country:US
Practice Address - Phone:702-671-5140
Practice Address - Fax:702-385-2745
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01065052A207VM0101X
MT8687207VM0101X
NV12911207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0017663Medicaid
NV12911OtherSTATE LICENSE
IN01065052AOtherSTATE LICENSE
MT8687OtherSTATE LICENSE
MT0017663Medicaid