Provider Demographics
NPI:1609653294
Name:JACKSON, RUBY LEE
Entity Type:Individual
Prefix:MRS
First Name:RUBY
Middle Name:LEE
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 1:2151 CITRUS HILLS AVE APT 1119
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-1753
Mailing Address - Country:US
Mailing Address - Phone:702-265-7065
Mailing Address - Fax:
Practice Address - Street 1:3930 HOWARD HUGHES PKWY STE 300
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89169-0946
Practice Address - Country:US
Practice Address - Phone:702-560-2217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-08
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty