Provider Demographics
NPI:1073020020
Name:JACKSON, MAURICE D (RBT)
Entity Type:Individual
Prefix:
First Name:MAURICE
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1623 BINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-5529
Mailing Address - Country:US
Mailing Address - Phone:850-294-8267
Mailing Address - Fax:
Practice Address - Street 1:6985 NEXUS CT STE 107
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3186
Practice Address - Country:US
Practice Address - Phone:910-728-4449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-29
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1790129740103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst