Basic Information
| Provider Information | |||||||||
| NPI: | 1821376344 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | SHAETONNA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MSW-LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 995 SIERRA VISTA DR | ||||||||
| Address2: | APT. 328 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891699387 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7656357698 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2820 W CHARLESTON BLVD | ||||||||
| Address2: | C23 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891021942 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024374673 | ||||||||
| FaxNumber: | 7024384673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2011 | ||||||||
| LastUpdateDate: | 09/08/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6011-S | NV | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | IC-691 | NV | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.