MEDICARE: CHANELL MALAN 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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1780101584
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHANELL MALAN JACKSON

Provider Business Mailing Address
First Line	:	4141 PALM AVE APT 490
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95842-4233
Country	:	US
Telephone Number	:	916-442-2396
Fax Number	:

Provider Business Practice Location Address
First Line	:	4141 PALM AVE APT 490
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95842-4233
Country	:	US
Telephone Number	:	916-582-9600
Fax Number	:

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

Provider Enumeration Date	:	08/23/2017
Last Update Date	:	08/23/2017

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Directions to “ CHANELL MALAN JACKSON ” Practice Location

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