Provider Demographics
NPI:1558848820
Name:KEITH, JACKIE S (EDD, LPA, BCBA-D)
Entity Type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:S
Last Name:KEITH
Suffix:
Gender:F
Credentials:EDD, LPA, BCBA-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 FM 1247
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:TX
Mailing Address - Zip Code:75925
Mailing Address - Country:US
Mailing Address - Phone:936-676-5866
Mailing Address - Fax:
Practice Address - Street 1:440 FM 1247
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:TX
Practice Address - Zip Code:75925
Practice Address - Country:US
Practice Address - Phone:936-676-5866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34214103T00000X
TX1612103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103T00000XBehavioral Health & Social Service ProvidersPsychologist