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NPI Code Detail

MEDICARE: MARY JACKSON

MEDICARE: MARY 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
1103K00000XBehavior Analyst1-21-57035IL
2106E00000XAssistant Behavior Analyst

General Provider Information

NPI Number : 1275144149
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARY JACKSON
Provider Business Mailing Address
First Line : 4559 BENES AVE
Second Line :
City : GLEN CARBON
State : IL
Zip : 62034-1541
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 4559 BENES AVE
Second Line :
City : GLEN CARBON
State : IL
Zip : 62034-1541
Country : US
Telephone Number : 217-525-8332
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/13/2020
Last Update Date : 07/03/2023

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Directions to “ MARY JACKSON ” Practice Location

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