Provider Demographics
NPI:1114309580
Name:JACKSON, AUNYA RENEE
Entity Type:Individual
Prefix:
First Name:AUNYA
Middle Name:RENEE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5537 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:JOINT BASE LEWIS MCCHORD
Mailing Address - State:WA
Mailing Address - Zip Code:98433-1127
Mailing Address - Country:US
Mailing Address - Phone:915-204-3436
Mailing Address - Fax:
Practice Address - Street 1:5537 N 4TH ST
Practice Address - Street 2:
Practice Address - City:JOINT BASE LEWIS MCCHORD
Practice Address - State:WA
Practice Address - Zip Code:98433-1127
Practice Address - Country:US
Practice Address - Phone:915-204-3436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-22
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60579395103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst