Provider Demographics
NPI:1770908311
Name:JACKSON, DRAKE EDWARD
Entity type:Individual
Prefix:
First Name:DRAKE
Middle Name:EDWARD
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 1:9400 BERMUDA RD APT 379
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89123-4420
Mailing Address - Country:US
Mailing Address - Phone:323-681-5278
Mailing Address - Fax:
Practice Address - Street 1:9400 S. BERMUDA RD. APT 379
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89123-4420
Practice Address - Country:US
Practice Address - Phone:323-681-5278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-19
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management