Provider Demographics
NPI:1558025098
Name:JACKSON, MATTHEW CURTIS JR
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:CURTIS
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 1:6170 BOULDER HWY APT 1006
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89122-7705
Mailing Address - Country:US
Mailing Address - Phone:909-433-0060
Mailing Address - Fax:
Practice Address - Street 1:1155 E TWAIN AVE STE 108
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89169-4216
Practice Address - Country:US
Practice Address - Phone:209-204-5672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-29
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion