Healthcare Provider Details

I. General information

NPI: 1831033265
Provider Name (Legal Business Name): NATHANIEL JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

4400 DR MARTIN LUTHER KING JR BLVD
KANSAS CITY MO
64130-2870
US

IV. Provider business mailing address

4400 DR MARTIN LUTHER KING JR BLVD
KANSAS CITY MO
64130-2870
US

V. Phone/Fax

Practice location:
  • Phone: 816-994-5693
  • Fax:
Mailing address:
  • Phone: 816-994-5693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-530076
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: