Provider Demographics
NPI:1790107076
Name:JACKSON, ALICISIA CLARISSA
Entity Type:Individual
Prefix:MISS
First Name:ALICISIA
Middle Name:CLARISSA
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 1:1941 NAPOLEON DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89156-7187
Mailing Address - Country:US
Mailing Address - Phone:702-438-8452
Mailing Address - Fax:702-438-2981
Practice Address - Street 1:1941 NAPOLEON DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89156-7187
Practice Address - Country:US
Practice Address - Phone:702-438-8452
Practice Address - Fax:702-438-2981
Is Sole Proprietor?:No
Enumeration Date:2014-01-06
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner