Healthcare Provider Details

I. General information

NPI: 1649028143
Provider Name (Legal Business Name): KHALIYAH JACKSON RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2024
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9905 FALL CREEK RD
INDIANAPOLIS IN
46256-4804
US

IV. Provider business mailing address

5663 LIBERTY CREEK DR E
INDIANAPOLIS IN
46254-1004
US

V. Phone/Fax

Practice location:
  • Phone: 317-813-4690
  • Fax: 317-845-1886
Mailing address:
  • Phone: 317-652-9460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-271743
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: