Provider Demographics
NPI:1043870892
Name:JACKSON, DARRYL MAURICE
Entity Type:Individual
Prefix:
First Name:DARRYL
Middle Name:MAURICE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 MCCOOK CIR NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-3156
Mailing Address - Country:US
Mailing Address - Phone:904-501-5304
Mailing Address - Fax:678-653-7865
Practice Address - Street 1:328 MCCOOK CIR NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-3156
Practice Address - Country:US
Practice Address - Phone:904-501-5304
Practice Address - Fax:678-653-7865
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-14
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician