Provider Demographics
NPI:1407279326
Name:JACKSON, KRYSTAL LONEA
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:LONEA
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 1:1840 N DECATUR BLVD UNIT 204
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-2269
Mailing Address - Country:US
Mailing Address - Phone:331-222-1181
Mailing Address - Fax:
Practice Address - Street 1:5005 LOSEE RD APT 1031
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89081-2490
Practice Address - Country:US
Practice Address - Phone:702-624-6618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-28
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health