Provider Demographics
NPI:1497489264
Name:JACKSON, KALEENA
Entity Type:Individual
Prefix:
First Name:KALEENA
Middle Name:
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 1:2575 MONTESSOURI ST STE 201
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-3060
Mailing Address - Country:US
Mailing Address - Phone:702-204-7252
Mailing Address - Fax:
Practice Address - Street 1:2575 MONTESSOURI ST STE 201
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-3060
Practice Address - Country:US
Practice Address - Phone:702-204-7252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-15
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant