Provider Demographics
NPI:1114606332
Name:JACKSON, BROOKE LYNN
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:LYNN
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 1:2710 N MASON RD STE 170
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77449-4180
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2710 N MASON RD STE 170
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77449-4180
Practice Address - Country:US
Practice Address - Phone:281-505-9338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-14
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-23-272468106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician