Provider Demographics
NPI:1659828564
Name:JACKSON, DAVID WAYNE II (MED, BCBA)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:WAYNE
Last Name:JACKSON
Suffix:II
Gender:M
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 1:5526 N ACADEMY BLVD STE 109
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-3688
Mailing Address - Country:US
Mailing Address - Phone:719-301-5100
Mailing Address - Fax:719-960-2649
Practice Address - Street 1:5526 N ACADEMY BLVD STE 109
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-3688
Practice Address - Country:US
Practice Address - Phone:719-301-5100
Practice Address - Fax:719-960-2649
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-08
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-16-22915103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst