Provider Demographics
NPI:1801202635
Name:JACKSON, VINCENT MAURICE SR
Entity Type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:MAURICE
Last Name:JACKSON
Suffix:SR
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 1:875 MASS AVE UNIT 205
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46204-1652
Mailing Address - Country:US
Mailing Address - Phone:317-679-5849
Mailing Address - Fax:
Practice Address - Street 1:875 MASS AVE UNIT 205
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46204-1652
Practice Address - Country:US
Practice Address - Phone:317-679-5849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-01
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst