MEDICARE: TYRA M JACKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician		TX

General Provider Information

NPI Number	:	1194669770
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYRA M JACKSON

Provider Business Mailing Address
First Line	:	4746 MONTCLAIR HILL LN
Second Line	:
City	:	FRESNO
State	:	TX
Zip	:	77545-2046
Country	:	US
Telephone Number	:	832-892-3164
Fax Number	:

Provider Business Practice Location Address
First Line	:	4746 MONTCLAIR HILL LN
Second Line	:
City	:	FRESNO
State	:	TX
Zip	:	77545-2046
Country	:	US
Telephone Number	:	832-892-3164
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/15/2026
Last Update Date	:	04/15/2026

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