MEDICARE: DESTINY 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	103K00000X	Behavior Analyst		GA

General Provider Information

NPI Number	:	1861335580
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESTINY JACKSON

Provider Business Mailing Address
First Line	:	1240 OHARA DR
Second Line	:	2304
City	:	JONESBORO
State	:	GA
Zip	:	30236
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1240 OHARA DR
Second Line	:	2304
City	:	JONESBORO
State	:	GA
Zip	:	30236
Country	:	US
Telephone Number	:	678-228-0936
Fax Number	:

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

Provider Enumeration Date	:	04/09/2026
Last Update Date	:	04/09/2026

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Directions to “ DESTINY JACKSON ” Practice Location

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