=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194647842
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OLIVER FRANK JACKSON III RBT-24-383753
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2026
-----------------------------------------------------
Last Update Date | 07/27/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3557 MAIN ST
-----------------------------------------------------
City | COLLEGE PARK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30337-2624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-376-0998
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3557 MAIN ST
-----------------------------------------------------
City | COLLEGE PARK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30337-2624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-376-0998
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number | RBT-24-383753
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------