Provider Demographics
NPI:1003392028
Name:JACKSON, RENEE CAMILLE (BCBA)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:CAMILLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4716 VENITO ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-4590
Mailing Address - Country:US
Mailing Address - Phone:678-201-7111
Mailing Address - Fax:
Practice Address - Street 1:6515 HOLT RD
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37211-6903
Practice Address - Country:US
Practice Address - Phone:615-832-0059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1-18-31297103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty