Provider Demographics
NPI:1972844363
Name:JACKSON, ROBERT E
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:E
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 RAINBOW GLOW ST
Mailing Address - Street 2:
Mailing Address - City:N LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89030-3709
Mailing Address - Country:US
Mailing Address - Phone:702-496-6156
Mailing Address - Fax:
Practice Address - Street 1:2605 RAINBOW GLOW ST
Practice Address - Street 2:
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-3709
Practice Address - Country:US
Practice Address - Phone:702-496-6156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-08
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner