Provider Demographics
NPI:1487682076
Name:BRANDON JACKSON, P T
Entity Type:Organization
Organization Name:BRANDON JACKSON, P T
Other - Org Name:JACKSON PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:LEROY
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:702-898-7633
Mailing Address - Street 1:4765 S. DURANGO DR.
Mailing Address - Street 2:STE 106
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147
Mailing Address - Country:US
Mailing Address - Phone:702-898-7633
Mailing Address - Fax:702-898-6433
Practice Address - Street 1:4765 S. DURANGO DR.
Practice Address - Street 2:STE 106
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89147
Practice Address - Country:US
Practice Address - Phone:702-898-7633
Practice Address - Fax:702-898-6433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1365225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100506016Medicaid
NV100506016Medicaid