Provider Demographics
NPI:1376012583
Name:JACKSON, JECOLIAH (RBT)
Entity Type:Individual
Prefix:MS
First Name:JECOLIAH
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8612 RAMONA ST APT B
Mailing Address - Street 2:
Mailing Address - City:BELLFLOWER
Mailing Address - State:CA
Mailing Address - Zip Code:90706-7744
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4001 WESTERLY PL STE 110
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2302
Practice Address - Country:US
Practice Address - Phone:949-756-8799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-16
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst