MEDICARE: KELY-MARIE 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		FL

General Provider Information

NPI Number	:	1356971360
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELY-MARIE JACKSON

Provider Business Mailing Address
First Line	:	1516 12TH AVE N
Second Line	:
City	:	JAX BCH
State	:	FL
Zip	:	32250-2834
Country	:	US
Telephone Number	:	904-982-2814
Fax Number	:

Provider Business Practice Location Address
First Line	:	9141 CYPRESS GREEN DR STE 2
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-2006
Country	:	US
Telephone Number	:	904-647-1849
Fax Number	:

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

Provider Enumeration Date	:	01/17/2020
Last Update Date	:	01/17/2020

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