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General NPI Number Information
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NPI Number | 1376012583
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Entity Type | Individual
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Provider Name | JECOLIAH JACKSON RBT
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Gender | Female
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Dates
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Enumeration Date | 11/16/2018
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Last Update Date | 11/16/2018
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Provider Practice Location Address
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Address Line | 4001 WESTERLY PL STE 110
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City | NEWPORT BEACH
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State | CA
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Zip | 92660-2302
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Country | US
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Telephone | 949-756-8799
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Fax |
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Provider Business Mailing Address
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Address Line | 8612 RAMONA ST APT B
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City | BELLFLOWER
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State | CA
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Zip | 90706-7744
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Country | US
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Telephone |
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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 | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number |
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License Number State | CA
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