Provider Demographics
NPI:1497535520
Name:JACKSON, EMRIC JAVAN (RBT)
Entity Type:Individual
Prefix:
First Name:EMRIC
Middle Name:JAVAN
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 1:5163 INDIAN RIVER DR UNIT 194
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-6142
Mailing Address - Country:US
Mailing Address - Phone:678-948-8822
Mailing Address - Fax:
Practice Address - Street 1:8064 W SAHARA AVE STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-1998
Practice Address - Country:US
Practice Address - Phone:702-829-8929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-05
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NVRBT3777106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician