Healthcare Provider Details

I. General information

NPI: 1417450974
Provider Name (Legal Business Name): KAILYN M JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2018
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 CONCORD AVE STE 185
CONCORD CA
94520-5006
US

IV. Provider business mailing address

1200 CONCORD AVE STE 185
CONCORD CA
94520-5006
US

V. Phone/Fax

Practice location:
  • Phone: 832-265-2507
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number17-0422-73709
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: