Provider Demographics
NPI:1760098768
Name:JACKSON, ADRIANNE NICOLE
Entity Type:Individual
Prefix:MS
First Name:ADRIANNE
Middle Name:NICOLE
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 1:7129 ALTA DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89145-5207
Mailing Address - Country:US
Mailing Address - Phone:702-472-5441
Mailing Address - Fax:
Practice Address - Street 1:7351 W CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-1502
Practice Address - Country:US
Practice Address - Phone:702-470-0620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician