Provider Demographics
NPI:1518185909
Name:JACKSON, MICHAEL S (CSA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:S
Last Name:JACKSON
Suffix:
Gender:M
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 70303
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89570-0303
Mailing Address - Country:US
Mailing Address - Phone:775-250-1564
Mailing Address - Fax:775-828-0580
Practice Address - Street 1:2739 CHAVEZ DR
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-4982
Practice Address - Country:US
Practice Address - Phone:775-329-3188
Practice Address - Fax:775-828-0580
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246ZS0410X
DC1700246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1700OtherNSAA