Provider Demographics
NPI:1710428826
Name:JACKSON, RACHEL (RBT)
Entity Type:Individual
Prefix:MS
First Name:RACHEL
Middle Name:
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:PO BOX 4323
Mailing Address - Street 2:
Mailing Address - City:WEST WENDOVER
Mailing Address - State:NV
Mailing Address - Zip Code:89883-4323
Mailing Address - Country:US
Mailing Address - Phone:801-651-4407
Mailing Address - Fax:
Practice Address - Street 1:3256 SKY VIEW DR
Practice Address - Street 2:BOX 4323
Practice Address - City:WEST WENDOVER
Practice Address - State:NV
Practice Address - Zip Code:89883-3659
Practice Address - Country:US
Practice Address - Phone:801-651-4407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-09
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-16-13032106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician