Provider Demographics
NPI:1548753700
Name:JACKSON, HOLLY JEAN (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:JEAN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1432
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97709-1432
Mailing Address - Country:US
Mailing Address - Phone:541-480-2570
Mailing Address - Fax:
Practice Address - Street 1:19800 VILLAGE OFFICE CT
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1872
Practice Address - Country:US
Practice Address - Phone:541-480-2570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-12
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
ORABA-AB-10225705106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1-23-66904OtherBEHAVIOR ANALYST CERTIFICATION BOARD