Provider Demographics
NPI:1689251183
Name:JACKSON PSYCHIATRIC AND PRIMARY CARE SERVICES LLC
Entity Type:Organization
Organization Name:JACKSON PSYCHIATRIC AND PRIMARY CARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:SIMONE
Authorized Official - Middle Name:NICOLA
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:901-283-1975
Mailing Address - Street 1:9005 W OQUENDO RD APT 3036
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-1524
Mailing Address - Country:US
Mailing Address - Phone:901-283-1975
Mailing Address - Fax:
Practice Address - Street 1:9005 W OQUENDO RD APT 3036
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-1524
Practice Address - Country:US
Practice Address - Phone:901-283-1975
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-29
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty