MEDICARE: KALIYAH JACKSON BT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1427911007
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KALIYAH JACKSON BT

Provider Business Mailing Address
First Line	:	PO BOX 10267
Second Line	:
City	:	CONWAY
State	:	AR
Zip	:	72034-0003
Country	:	US
Telephone Number	:	501-358-6535
Fax Number	:	501-358-6536

Provider Business Practice Location Address
First Line	:	4328 CENTRAL AVE
Second Line	:
City	:	HOT SPRINGS
State	:	AR
Zip	:	71913-7436
Country	:	US
Telephone Number	:	501-358-6535
Fax Number	:	501-358-6536

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/09/2025
Last Update Date	:	12/09/2025

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