Provider Demographics
NPI:1396396370
Name:JACKSON, SARAH TINA
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:TINA
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 1:509 HANSKA WAY
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-2265
Mailing Address - Country:US
Mailing Address - Phone:856-558-0259
Mailing Address - Fax:
Practice Address - Street 1:8117 EBENEZER CHURCH RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-7307
Practice Address - Country:US
Practice Address - Phone:984-263-0654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-22
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC106S00000X
NC1-22-63279103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1-22-63279OtherBACB