Provider Demographics
NPI:1801196878
Name:JACKSON, REGINA
Entity type:Individual
Prefix:MS
First Name:REGINA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REGINA
Other - Middle Name:
Other - Last Name:JACKSON-CHRISTOPHER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5254 PARADISE SKIES AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89156-5654
Mailing Address - Country:US
Mailing Address - Phone:702-445-5858
Mailing Address - Fax:
Practice Address - Street 1:5254 PARADISE SKIES AVENUE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89156
Practice Address - Country:US
Practice Address - Phone:702-445-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-25
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner