Healthcare Provider Details

I. General information

NPI: 1154569564
Provider Name (Legal Business Name): LYNSEY M JACKSON BCABA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2009
Last Update Date: 01/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14110 CYPRESS CREEK BLVD
CYPRESS TX
77429-3214
US

IV. Provider business mailing address

14110 CYPRESS CREEK BLVD
CYPRESS TX
77429-3214
US

V. Phone/Fax

Practice location:
  • Phone: 281-894-1423
  • Fax: 281-894-1423
Mailing address:
  • Phone: 281-894-1423
  • Fax: 281-894-1423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number008-2660
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number008-2660
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: