Healthcare Provider Details

I. General information

NPI: 1841623790
Provider Name (Legal Business Name): MARIANNE LOUISE JACKSON BCBA-D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2013
Last Update Date: 08/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4910 N CHESTNUT AVE
FRESNO CA
93726-1852
US

IV. Provider business mailing address

4910 N CHESTNUT AVE
FRESNO CA
93726-1852
US

V. Phone/Fax

Practice location:
  • Phone: 559-278-2757
  • Fax:
Mailing address:
  • Phone: 559-278-2757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number1-07-3824
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: