Provider Demographics
NPI:1417402967
Name:JACKSON, ORVEL DONALD
Entity Type:Individual
Prefix:MR
First Name:ORVEL
Middle Name:DONALD
Last Name:JACKSON
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 1:6825 MAVERICK VALLEY PL
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89131-6124
Mailing Address - Country:US
Mailing Address - Phone:561-419-4844
Mailing Address - Fax:
Practice Address - Street 1:6655 W SAHARA AVE
Practice Address - Street 2:STE D 106
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-0842
Practice Address - Country:US
Practice Address - Phone:702-365-0600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst