Healthcare Provider Details

I. General information

NPI: 1508777194
Provider Name (Legal Business Name): KYILEI JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 E NORTHFIELD DR STE 100
BROWNSBURG IN
46112-2415
US

IV. Provider business mailing address

157 N MICKLEY AVE
INDIANAPOLIS IN
46224-8709
US

V. Phone/Fax

Practice location:
  • Phone: 317-742-9025
  • Fax:
Mailing address:
  • Phone: 317-702-3127
  • 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: