Provider Demographics
NPI:1215594676
Name:JACKSON, GABRIELLE MARIE (MS, BCBA)
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1063 MCGAW AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-5505
Mailing Address - Country:US
Mailing Address - Phone:714-720-3457
Mailing Address - Fax:
Practice Address - Street 1:1063 MCGAW AVE
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-5505
Practice Address - Country:US
Practice Address - Phone:714-720-3457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-21
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA12042476103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician