Provider Demographics
NPI:1114686524
Name:JACKSON, SOPHIE (BS RBT)
Entity Type:Individual
Prefix:
First Name:SOPHIE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:BS RBT
Other - Prefix:
Other - First Name:SOPHIE
Other - Middle Name:
Other - Last Name:FLOYD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BS RBT
Mailing Address - Street 1:1959 N PEACE HAVEN RD STE 104
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-4850
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4264 SADDLEWOOD FOREST DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106
Practice Address - Country:US
Practice Address - Phone:336-560-7878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-13
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician