=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013863315
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMPOWERED NEUROSCIENCE THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2026
-----------------------------------------------------
Last Update Date | 03/09/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4812 TECHNOLOGY DR BLDG 1
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30907-3912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-583-1636
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 933 BRANCH CT
-----------------------------------------------------
City | GROVETOWN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30813-3325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-583-1636
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SARA JACKSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 702-583-1636
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------