Healthcare Provider Details

I. General information

NPI: 1043128911
Provider Name (Legal Business Name): MADISON JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 DUNWOODY PARK
ATLANTA GA
30338-7404
US

IV. Provider business mailing address

3290 COBB GALLERIA PKWY UNIT 15138
ATLANTA GA
30339-6389
US

V. Phone/Fax

Practice location:
  • Phone: 770-804-8444
  • Fax:
Mailing address:
  • Phone: 404-640-8130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-353775
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: