Provider Demographics
NPI:1396225736
Name:JACKSON-HALEY, DESTINY SHARAD
Entity Type:Individual
Prefix:
First Name:DESTINY
Middle Name:SHARAD
Last Name:JACKSON-HALEY
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 1:1024 W OWENS AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-2520
Mailing Address - Country:US
Mailing Address - Phone:702-877-9850
Mailing Address - Fax:
Practice Address - Street 1:1024 W OWENS AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-2520
Practice Address - Country:US
Practice Address - Phone:702-877-9850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician