Provider Demographics
NPI:1841571478
Name:JACKSON, WILLIE PEARL
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:PEARL
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 1:5304 ROSELAND AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-2635
Mailing Address - Country:US
Mailing Address - Phone:702-630-5009
Mailing Address - Fax:702-631-9821
Practice Address - Street 1:5304 ROSELAND AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-2635
Practice Address - Country:US
Practice Address - Phone:702-630-5009
Practice Address - Fax:702-631-9821
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-09
Last Update Date:2019-10-18
Deactivation Date:2019-10-10
Deactivation Code:
Reactivation Date:2019-10-18
Provider Licenses
StateLicense IDTaxonomies
NV103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1841571478Medicaid