MEDICARE: KELSEY MARIE JACKSON BCBA

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

General Provider Information

NPI Number	:	1992475719
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELSEY MARIE JACKSON BCBA

Provider Business Mailing Address
First Line	:	8604 LOUIS DR SE
Second Line	:
City	:	HUNTSVILLE
State	:	AL
Zip	:	35802-3528
Country	:	US
Telephone Number	:	361-401-1734
Fax Number	:

Provider Business Practice Location Address
First Line	:	8604 LOUIS DR SE
Second Line	:
City	:	HUNTSVILLE
State	:	AL
Zip	:	35802-3528
Country	:	US
Telephone Number	:	361-401-1734
Fax Number	:

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

Provider Enumeration Date	:	09/14/2021
Last Update Date	:	09/14/2021

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