1790107076 NPI number — MISS ALICISIA CLARISSA JACKSON

Table of content: MISS ALICISIA CLARISSA JACKSON (NPI 1790107076)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790107076 NPI number — MISS ALICISIA CLARISSA JACKSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
ALICISIA
Provider Middle Name:
CLARISSA
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790107076
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/06/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1941 NAPOLEON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89156-7187
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-438-8452
Provider Business Mailing Address Fax Number:
702-438-2981

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1941 NAPOLEON DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89156-7187
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-438-8452
Provider Business Practice Location Address Fax Number:
702-438-2981
Provider Enumeration Date:
01/06/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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