Provider Demographics
NPI:1457669848
Name:JACKSON, CHARLES EDWARD JR
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:EDWARD
Last Name:JACKSON
Suffix:JR
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 1:1407 HEALING WATERS LN
Mailing Address - Street 2:
Mailing Address - City:N LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-1803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1407 HEALING WATER LANE
Practice Address - Street 2:
Practice Address - City:N.LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031
Practice Address - Country:US
Practice Address - Phone:702-485-0883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-20
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation