Provider Demographics
NPI:1710452578
Name:CANADA, JACKLYN DREW
Entity Type:Individual
Prefix:
First Name:JACKLYN
Middle Name:DREW
Last Name:CANADA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACKLYN
Other - Middle Name:DREW
Other - Last Name:MURPHY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:#216 DOS AMANTES PLAZA
Mailing Address - Street 2:
Mailing Address - City:UPPER TUMON
Mailing Address - State:GU
Mailing Address - Zip Code:96913
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:DOS AMANTES PLAZA
Practice Address - Street 2:#216
Practice Address - City:UPPER TUMON
Practice Address - State:GU
Practice Address - Zip Code:96913
Practice Address - Country:US
Practice Address - Phone:671-487-5493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-09
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRBT-16-17529106S00000X
GU1-20-40615103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000OtherDO NOT HAVE ONE