Healthcare Provider Details

I. General information

NPI: 1548109556
Provider Name (Legal Business Name): JACKLYNN SEVERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2026
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 STANDIFORD AVE STE B
MODESTO CA
95350-1000
US

IV. Provider business mailing address

129 W POPLAR ST APT 10
STOCKTON CA
95202-1626
US

V. Phone/Fax

Practice location:
  • Phone: 877-418-2978
  • Fax:
Mailing address:
  • Phone: 530-443-6349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: