Provider Demographics
NPI:1588011233
Name:JACKMAN, KRYSTAL (MS, BCBA)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:JACKMAN
Suffix:
Gender:F
Credentials:MS, 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 1564
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33568-1564
Mailing Address - Country:US
Mailing Address - Phone:813-610-5186
Mailing Address - Fax:
Practice Address - Street 1:10722 STANDING STONE DR
Practice Address - Street 2:
Practice Address - City:WIMAUMA
Practice Address - State:FL
Practice Address - Zip Code:33598-6163
Practice Address - Country:US
Practice Address - Phone:813-610-5186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-23
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001289800Medicaid