Provider Demographics
NPI:1639527112
Name:JACKSON, TANYA L (ABA TECHNICIAN)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ABA TECHNICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3916 STONEGATE
Mailing Address - Street 2:CENTRIA HEALTHCARE
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49022
Mailing Address - Country:US
Mailing Address - Phone:269-252-1540
Mailing Address - Fax:
Practice Address - Street 1:1220 PEARL ST
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-5539
Practice Address - Country:US
Practice Address - Phone:269-252-1540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-25
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other