Provider Demographics
NPI:1740730118
Name:JACKSON, CANNELL
Entity type:Individual
Prefix:
First Name:CANNELL
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 1:2725 W. WIGWAM AVE #2009
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89123
Mailing Address - Country:US
Mailing Address - Phone:773-844-6231
Mailing Address - Fax:
Practice Address - Street 1:2725 W. WIGWAM AVE #2009
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89123
Practice Address - Country:US
Practice Address - Phone:773-844-6231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-10
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner