Provider Demographics
NPI:1790547495
Name:JACKSON, CAMERON
Entity Type:Individual
Prefix:
First Name:CAMERON
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1117 CAMBOURNE DR
Mailing Address - Street 2:
Mailing Address - City:POINCIANA
Mailing Address - State:FL
Mailing Address - Zip Code:34758-2910
Mailing Address - Country:US
Mailing Address - Phone:407-577-0522
Mailing Address - Fax:
Practice Address - Street 1:1117 CAMBOURNE DR
Practice Address - Street 2:
Practice Address - City:POINCIANA
Practice Address - State:FL
Practice Address - Zip Code:34758-2910
Practice Address - Country:US
Practice Address - Phone:407-577-0522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician