Provider Demographics
NPI:1093594384
Name:MORENO, JACKLYN N (RBT,CPR)
Entity Type:Individual
Prefix:
First Name:JACKLYN
Middle Name:N
Last Name:MORENO
Suffix:
Gender:F
Credentials:RBT,CPR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11135 HARLEM RD STE 250
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77406-3657
Mailing Address - Country:US
Mailing Address - Phone:281-725-6325
Mailing Address - Fax:
Practice Address - Street 1:11135 HARLEM RD STE 250
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77406-3657
Practice Address - Country:US
Practice Address - Phone:281-725-6325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23254019106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician