Provider Demographics
NPI:1225710130
Name:JACKSON, HADLEY LOUISE
Entity Type:Individual
Prefix:
First Name:HADLEY
Middle Name:LOUISE
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 1:2061 N SAGINAW RD
Mailing Address - Street 2:
Mailing Address - City:AVON PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33825-8194
Mailing Address - Country:US
Mailing Address - Phone:863-446-1262
Mailing Address - Fax:
Practice Address - Street 1:326 N RIDGEWOOD DR UNIT C
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33870-7205
Practice Address - Country:US
Practice Address - Phone:786-332-6632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-280774106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician