Healthcare Provider Details

I. General information

NPI: 1407774805
Provider Name (Legal Business Name): PAYTON RYAN JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2888 LOKER AVE E STE 105
CARLSBAD CA
92010-6683
US

IV. Provider business mailing address

1234 HIGHBLUFF AVE
SAN MARCOS CA
92078-1051
US

V. Phone/Fax

Practice location:
  • Phone: 619-795-9925
  • Fax:
Mailing address:
  • Phone: 951-303-4513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-2826221
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: