Provider Demographics
NPI:1457892838
Name:JACKSON, ANTUAN
Entity Type:Individual
Prefix:
First Name:ANTUAN
Middle Name:
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 1:2920 S JONES BLVD
Mailing Address - Street 2:110B
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-5642
Mailing Address - Country:US
Mailing Address - Phone:702-968-9372
Mailing Address - Fax:702-932-3189
Practice Address - Street 1:2920 S JONES BLVD
Practice Address - Street 2:110B
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-5642
Practice Address - Country:US
Practice Address - Phone:702-968-9372
Practice Address - Fax:702-932-3189
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-17
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health