Provider Demographics
NPI:1568964955
Name:JACKSON, ELIA DIANA
Entity Type:Individual
Prefix:
First Name:ELIA
Middle Name:DIANA
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 1:417 FOXVALE AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032-6150
Mailing Address - Country:US
Mailing Address - Phone:702-463-0082
Mailing Address - Fax:702-643-1552
Practice Address - Street 1:417 FOXVALE AVE
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-6150
Practice Address - Country:US
Practice Address - Phone:702-463-0082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-02
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program