Healthcare Provider Details

I. General information

NPI: 1417615451
Provider Name (Legal Business Name): ONESTIE SABINE JACKSON BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2021
Last Update Date: 03/27/2023
Certification Date: 03/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 SMITH AVE
BALTIMORE MD
21209-2505
US

IV. Provider business mailing address

6609 WYCOMBE WAY APT C
PARKVILLE MD
21234-6751
US

V. Phone/Fax

Practice location:
  • Phone: 410-205-9493
  • Fax:
Mailing address:
  • Phone: 410-205-2315
  • Fax: 410-205-2312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-21-195595
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberLBA1496
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: