MEDICARE: MS. RACHEL JACKSON RBT

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	RBT-16-13032	CO

General Provider Information

NPI Number	:	1710428826
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. RACHEL JACKSON RBT

Provider Business Mailing Address
First Line	:	PO BOX 4323
Second Line	:
City	:	WEST WENDOVER
State	:	NV
Zip	:	89883-4323
Country	:	US
Telephone Number	:	801-651-4407
Fax Number	:

Provider Business Practice Location Address
First Line	:	3256 SKY VIEW DR
Second Line	:	BOX 4323
City	:	WEST WENDOVER
State	:	NV
Zip	:	89883-3659
Country	:	US
Telephone Number	:	801-651-4407
Fax Number	:

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

Provider Enumeration Date	:	03/09/2017
Last Update Date	:	03/09/2017

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