Provider Demographics
NPI:1619381548
Name:JACKSON, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:JACKSON
Suffix:
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 1:2470 WRONDEL WAY STE 275
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-3701
Mailing Address - Country:US
Mailing Address - Phone:775-354-3991
Mailing Address - Fax:775-336-1082
Practice Address - Street 1:2470 WRONDEL WAY STE 275
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-3701
Practice Address - Country:US
Practice Address - Phone:775-354-3991
Practice Address - Fax:775-336-1082
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-18
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV4200227759320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness