Healthcare Provider Details

I. General information

NPI: 1588935258
Provider Name (Legal Business Name): CARRIE RAE JACKSON MS, BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2012
Last Update Date: 01/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10715 BABCOCK BLVD
GIBSONIA PA
15044-8977
US

IV. Provider business mailing address

10715 BABCOCK BLVD
GIBSONIA PA
15044-8977
US

V. Phone/Fax

Practice location:
  • Phone: 412-498-9128
  • Fax: 724-502-4510
Mailing address:
  • Phone: 412-498-9128
  • Fax: 724-502-4510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number1-05-2589
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: