Provider Demographics
NPI:1255689261
Name:NIGHTSHADE, JACKSON CRYSES
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:CRYSES
Last Name:NIGHTSHADE
Suffix:
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 1:1027 S RAINBOW BLVD PMB 186
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89145-6232
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2300 W SAHARA AVE STE 800
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-4397
Practice Address - Country:US
Practice Address - Phone:702-545-5854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-22
Last Update Date:2023-08-04
Deactivation Date:2023-01-23
Deactivation Code:
Reactivation Date:2023-08-04
Provider Licenses
StateLicense IDTaxonomies
NVMI3202101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health