Provider Demographics
NPI:1851664031
Name:JACKSON, YVONNE RUTH
Entity Type:Individual
Prefix:
First Name:YVONNE
Middle Name:RUTH
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 1:4616 W SAHARA AVE
Mailing Address - Street 2:358
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-3654
Mailing Address - Country:US
Mailing Address - Phone:702-860-4689
Mailing Address - Fax:
Practice Address - Street 1:4616 W SAHARA AVE
Practice Address - Street 2:358
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-3654
Practice Address - Country:US
Practice Address - Phone:702-860-4689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-17
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health