Provider Demographics
NPI:1174190334
Name:KAT JACKSON LLC
Entity Type:Organization
Organization Name:KAT JACKSON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MED, BCBA, LBA
Authorized Official - Phone:808-780-9399
Mailing Address - Street 1:1401 LUSITANA ST APT 304
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-2041
Mailing Address - Country:US
Mailing Address - Phone:808-780-9399
Mailing Address - Fax:
Practice Address - Street 1:1401 LUSITANA ST APT 304
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2041
Practice Address - Country:US
Practice Address - Phone:808-780-9399
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1558829861Medicaid