Provider Demographics
NPI:1326783044
Name:JACKSON, PAUL JOHN
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:JOHN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 UNION DR STE 206
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-6652
Mailing Address - Country:US
Mailing Address - Phone:509-494-9191
Mailing Address - Fax:
Practice Address - Street 1:13322 I ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-1111
Practice Address - Country:US
Practice Address - Phone:402-230-5861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-28
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NERBT-22-213386106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician