=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932056264
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELIZABETH KOLB-JACKSON, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2026
-----------------------------------------------------
Last Update Date | 03/16/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4526 RIVERMIST DR
-----------------------------------------------------
City | MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32935-7163
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-972-4728
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4526 RIVERMIST DR
-----------------------------------------------------
City | MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32935-7163
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-972-4728
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DIRECTOR
-----------------------------------------------------
Name | ELIZABETH ANNE KOLB-JACKSON
-----------------------------------------------------
Credential | BCBA
-----------------------------------------------------
Telephone | 803-972-4728
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------