Healthcare Provider Details

I. General information

NPI: 1306741558
Provider Name (Legal Business Name): MADYLINE R JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

686 LESTER STREER
POPLAR BLUFF MO
63901-5025
US

IV. Provider business mailing address

686 LESTER STREER
POPLAR BLUFF MO
63901-5025
US

V. Phone/Fax

Practice location:
  • Phone: 573-873-6833
  • Fax:
Mailing address:
  • Phone: 573-873-6833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: