Provider Demographics
NPI:1659460814
Name:JACKSON, GRACE ELIZABETH (MD)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:ELIZABETH
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10721 DOVER CREEK AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89134-5250
Mailing Address - Country:US
Mailing Address - Phone:928-963-0343
Mailing Address - Fax:
Practice Address - Street 1:10721 DOVER CREEK AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89134-5250
Practice Address - Country:US
Practice Address - Phone:928-963-0343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV303252084P0800X
NV153202084P0800X
NC2002009222084P0800X
WY12228A2084P0800X
CAC560012084P0800X
HIMD-171012084P0800X
TN632172084P0800X
MDD00909402084P0800X
AZ467102084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ765156Medicaid
NC5913321Medicaid