Provider Demographics
NPI:1780421040
Name:JACKSON, DMOREA (RN)
Entity type:Individual
Prefix:
First Name:DMOREA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3912 BEVERLY ELMS ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129-3006
Mailing Address - Country:US
Mailing Address - Phone:310-951-2581
Mailing Address - Fax:
Practice Address - Street 1:3912 BEVERLY ELMS ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89129-3006
Practice Address - Country:US
Practice Address - Phone:310-951-2581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-12
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV876230163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health