Provider Demographics
NPI:1649538836
Name:JACKSON, PHELTON GERRARD (N/A)
Entity type:Individual
Prefix:MR
First Name:PHELTON
Middle Name:GERRARD
Last Name:JACKSON
Suffix:
Gender:M
Credentials:N/A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4417 OASIS PLAINS AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89085-2334
Mailing Address - Country:US
Mailing Address - Phone:702-688-1470
Mailing Address - Fax:702-688-1470
Practice Address - Street 1:4417 OASIS PLAINS AVE
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89085-2334
Practice Address - Country:US
Practice Address - Phone:702-688-1407
Practice Address - Fax:702-688-1407
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-25
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor