Provider Demographics
NPI:1497479034
Name:JACKSON, MYKEAL (RBT)
Entity Type:Individual
Prefix:
First Name:MYKEAL
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 LILIHA ST STE 406
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-3564
Mailing Address - Country:US
Mailing Address - Phone:714-584-9889
Mailing Address - Fax:
Practice Address - Street 1:1520 LILIHA ST STE 406
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-3564
Practice Address - Country:US
Practice Address - Phone:714-584-9889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-27
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician