Provider Demographics
NPI:1205266764
Name:BRANDON JACKSON PT
Entity type:Organization
Organization Name:BRANDON JACKSON PT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:702-845-1386
Mailing Address - Street 1:4765 S DURANGO DR
Mailing Address - Street 2:SUITE 106
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-8145
Mailing Address - Country:US
Mailing Address - Phone:702-898-7633
Mailing Address - Fax:702-898-6433
Practice Address - Street 1:4765 S DURANGO DR
Practice Address - Street 2:SUITE 106
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89147-8145
Practice Address - Country:US
Practice Address - Phone:702-898-7633
Practice Address - Fax:702-898-6433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-20
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV13652251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1487682076Medicaid
NV1487682076Medicaid