Healthcare Provider Details

I. General information

NPI: 1245183714
Provider Name (Legal Business Name): YVONNE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2026
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2113 FIRETHORN RD
MIDDLE RIVER MD
21220-4806
US

IV. Provider business mailing address

2113 FIRETHORN RD
MIDDLE RIVER MD
21220-4806
US

V. Phone/Fax

Practice location:
  • Phone: 443-571-3827
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: