Provider Demographics
NPI:1316548688
Name:JACKSON, SEQUOIA
Entity Type:Individual
Prefix:MRS
First Name:SEQUOIA
Middle Name:
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 1:5135 CAMINO AL NORTE STE 210
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-2391
Mailing Address - Country:US
Mailing Address - Phone:310-951-2985
Mailing Address - Fax:
Practice Address - Street 1:5135 CAMINO AL NORTE STE 230
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-2391
Practice Address - Country:US
Practice Address - Phone:702-690-9686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker