Basic Information
| Provider Information | |||||||||
| NPI: | 1235236308 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | NEAL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 W CHARLESTON BLVD | ||||||||
| Address2: | #215 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891022325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029684347 | ||||||||
| FaxNumber: | 7023825388 | ||||||||
| Practice Location | |||||||||
| Address1: | 1707 W CHARLESTON BLVD | ||||||||
| Address2: | #120 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891022351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026715140 | ||||||||
| FaxNumber: | 7023852745 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 04/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VM0101X | 01065052A | IN | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine | 207VM0101X | 8687 | MT | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine | 207VM0101X | 12911 | NV | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0017663 | 05 | MT | MEDICAID | 12911 | 01 | NV | STATE LICENSE | OTHER | 01065052A | 01 | IN | STATE LICENSE | OTHER | 8687 | 01 | MT | STATE LICENSE | OTHER |