Provider Demographics
NPI:1699384180
Name:JACKSON, KATRINA ELAINE (RBT)
Entity Type:Individual
Prefix:MS
First Name:KATRINA
Middle Name:ELAINE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1829 RUSHDEN DR
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-7708
Mailing Address - Country:US
Mailing Address - Phone:407-468-4721
Mailing Address - Fax:
Practice Address - Street 1:644 FERGUSON DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32805-1014
Practice Address - Country:US
Practice Address - Phone:407-574-4629
Practice Address - Fax:407-965-4263
Is Sole Proprietor?:No
Enumeration Date:2020-07-30
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician