Provider Demographics
NPI:1407557457
Name:JACKSON, TAYLOR NICOLE
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:NICOLE
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 1:1900 N WEST ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-1033
Mailing Address - Country:US
Mailing Address - Phone:601-718-7450
Mailing Address - Fax:
Practice Address - Street 1:1900 N WEST ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-1033
Practice Address - Country:US
Practice Address - Phone:601-718-7450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-16
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MSRBT-21-186836106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician