Healthcare Provider Details

I. General information

NPI: 1558226738
Provider Name (Legal Business Name): KATIE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2025
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7108 S KANNER HWY
STUART FL
34997-7462
US

IV. Provider business mailing address

4343 S GREENHAVEN ST
WICHITA KS
67216-2922
US

V. Phone/Fax

Practice location:
  • Phone: 316-883-7332
  • Fax:
Mailing address:
  • Phone: 316-883-7332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: