MEDICARE: LACEY KRISTINE JACKSON

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	103K00000X	Behavior Analyst	3591	TX

General Provider Information

NPI Number	:	1639794746
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LACEY KRISTINE JACKSON

Provider Business Mailing Address
First Line	:	1537 E GRANDE BLVD
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75703-3900
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1537 E GRANDE BLVD
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75703-3900
Country	:	US
Telephone Number	:	903-630-7077
Fax Number	:

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

Provider Enumeration Date	:	06/15/2020
Last Update Date	:	10/08/2025

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