Healthcare Provider Details

I. General information

NPI: 1194647842
Provider Name (Legal Business Name): OLIVER FRANK JACKSON III RBT-24-383753
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3557 MAIN ST
COLLEGE PARK GA
30337-2624
US

IV. Provider business mailing address

3557 MAIN ST
COLLEGE PARK GA
30337-2624
US

V. Phone/Fax

Practice location:
  • Phone: 770-376-0998
  • Fax:
Mailing address:
  • Phone: 770-376-0998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-383753
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: