Provider Demographics
NPI:1841790813
Name:JACKSON, BRUNA
Entity Type:Individual
Prefix:
First Name:BRUNA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRUNA
Other - Middle Name:
Other - Last Name:PEVIDOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9070 KIMBERLY BLVD STE 19-20
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33434-2855
Mailing Address - Country:US
Mailing Address - Phone:954-988-0918
Mailing Address - Fax:954-827-7625
Practice Address - Street 1:9070 KIMBERLY BLVD STE 19-20
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33434-2855
Practice Address - Country:US
Practice Address - Phone:954-988-0918
Practice Address - Fax:954-827-7625
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-16
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL02414985106E00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst