Healthcare Provider Details

I. General information

NPI: 1104166776
Provider Name (Legal Business Name): JACKSON AUTISM CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2013
Last Update Date: 02/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 COLONIAL CIR
JACKSON MS
39211-4213
US

IV. Provider business mailing address

314 COLONIAL CIR
JACKSON MS
39211-4213
US

V. Phone/Fax

Practice location:
  • Phone: 769-218-9596
  • Fax:
Mailing address:
  • Phone: 769-218-9596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. REBECCA MULLICAN
Title or Position: BEHAVIOR INTERVENTIONIST
Credential: PHD
Phone: 769-218-9596