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General NPI Number Information
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NPI Number | 1366123838
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Entity Type | Individual
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Provider Name | GWEN D JACKSON RBT
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Gender | Female
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Dates
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Enumeration Date | 07/27/2023
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Last Update Date | 02/21/2025
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Provider Practice Location Address
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Address Line | 330 W EDMOND RD
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City | EDMOND
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State | OK
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Zip | 73003-5600
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Country | US
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Telephone | 405-216-3391
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Fax | 405-216-3391
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Provider Business Mailing Address
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Address Line | 330 W EDMOND RD
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City | EDMOND
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State | OK
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Zip | 73003-5600
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Country | US
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Telephone | 405-216-3391
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Fax | 405-216-3391
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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 | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number | RBT-22-251702
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License Number State | TX
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