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NPI Code Detail

MEDICARE: MR. SHAWNEE JACKSON RBT

MEDICARE: MR. SHAWNEE JACKSON RBT
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
1106S00000XBehavior TechnicianRBT-25-427194IL

General Provider Information

NPI Number : 1508651829
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. SHAWNEE JACKSON RBT
Provider Business Mailing Address
First Line : 5221 6TH STREET FRONTAGE RD E
Second Line :
City : SPRINGFIELD
State : IL
Zip : 62703-5190
Country : US
Telephone Number : 217-292-1983
Fax Number : 217-614-4092
Provider Business Practice Location Address
First Line : 5221 6TH STREET FRONTAGE RD E
Second Line :
City : SPRINGFIELD
State : IL
Zip : 62703-5190
Country : US
Telephone Number : 217-292-1983
Fax Number : 217-614-4092
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/09/2025
Last Update Date : 04/10/2025

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