Healthcare Provider Details

I. General information

NPI: 1770447971
Provider Name (Legal Business Name): MIKAYLA SHYANN JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2025
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 W RED BANK AVE
WOODBURY NJ
08096-1630
US

IV. Provider business mailing address

PO BOX 360595, PITTSBURGH PA 15251 PO BOX 360595
PITTSBURGH PA
15251-0001
US

V. Phone/Fax

Practice location:
  • Phone: 718-215-5311
  • Fax: 718-865-5165
Mailing address:
  • Phone: 718-215-5311
  • Fax: 718-865-5165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: