Provider Demographics
NPI:1356067052
Name:JACKSON, BREIYANNA L
Entity type:Individual
Prefix:
First Name:BREIYANNA
Middle Name:L
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 1:8611 LAVENDER RIDGE ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89131-1101
Mailing Address - Country:US
Mailing Address - Phone:702-406-1149
Mailing Address - Fax:
Practice Address - Street 1:1701 N GREEN VALLEY PKWY STE 8C
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-5990
Practice Address - Country:US
Practice Address - Phone:725-444-3803
Practice Address - Fax:702-441-0356
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-13
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRBT-22-227966106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician