Provider Demographics
NPI:1659738292
Name:JACKSON, GAYLE
Entity Type:Individual
Prefix:
First Name:GAYLE
Middle Name:
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 1:2624 RUE TOULOUSE AVE
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89044-0416
Mailing Address - Country:US
Mailing Address - Phone:214-995-4954
Mailing Address - Fax:702-656-5685
Practice Address - Street 1:2624 RUE TOULOUSE AVE
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89044-0416
Practice Address - Country:US
Practice Address - Phone:214-995-4954
Practice Address - Fax:702-656-5685
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-27
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner