Basic Information
| Provider Information | |||||||||
| NPI: | 1760022214 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DR. WILLIAM JACKSON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 480 GALLETTI WAY | ||||||||
| Address2: | |||||||||
| City: | SPARKS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 894315564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7756880400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 480 GALLETTI WAY | ||||||||
| Address2: | |||||||||
| City: | SPARKS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 894315564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7756880400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2020 | ||||||||
| LastUpdateDate: | 01/13/2020 | ||||||||
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| AuthorizedOfficialLastName: | CONWAY | ||||||||
| AuthorizedOfficialFirstName: | LYNN | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGEMENT ANALYST II | ||||||||
| AuthorizedOfficialTelephone: | 7756880400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
No ID Information.