Provider Demographics
NPI:1477187516
Name:JACKSON, KELLIEN MICHELLE
Entity Type:Individual
Prefix:
First Name:KELLIEN
Middle Name:MICHELLE
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 1:10333 RESEARCH FOREST DR APT 537
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:TX
Mailing Address - Zip Code:77354-6166
Mailing Address - Country:US
Mailing Address - Phone:281-468-0645
Mailing Address - Fax:
Practice Address - Street 1:2515 SUPERIOR RD
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:TX
Practice Address - Zip Code:77354-1431
Practice Address - Country:US
Practice Address - Phone:346-225-7998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-27
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician