MEDICARE: PATRICK 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-19-78853.	WY

General Provider Information

NPI Number	:	1962968560
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICK JACKSON RBT

Provider Business Mailing Address
First Line	:	918 EISENHOWER DR
Second Line	:
City	:	ROCK SPRINGS
State	:	WY
Zip	:	82901-4449
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	918 EISENHOWER DR
Second Line	:
City	:	ROCK SPRINGS
State	:	WY
Zip	:	82901-4449
Country	:	US
Telephone Number	:	307-399-1793
Fax Number	:

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

Provider Enumeration Date	:	02/19/2019
Last Update Date	:	02/19/2019

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