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General NPI Number Information
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NPI Number | 1003552696
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Entity Type | Individual
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Provider Name | CEYLI JACKSON
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Gender | Female
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Dates
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Enumeration Date | 05/07/2022
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Last Update Date | 09/14/2022
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Provider Practice Location Address
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Address Line | 5100 PECAN BROOK DR
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City | AUSTIN
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State | TX
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Zip | 78724-3302
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Country | US
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Telephone | 512-537-1957
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 113
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City | MANOR
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State | TX
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Zip | 78653-0113
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Country | US
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Telephone | 512-537-1957
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101200000X
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Taxonomy Name | Drama Therapist
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License Number |
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License Number State |
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