Provider Demographics
NPI:1851876940
Name:JACKSON, CRISSY STARR (BCBA, LBA, IBA)
Entity Type:Individual
Prefix:MRS
First Name:CRISSY
Middle Name:STARR
Last Name:JACKSON
Suffix:
Gender:F
Credentials:BCBA, LBA, IBA
Other - Prefix:MISS
Other - First Name:CRISSY
Other - Middle Name:STARR
Other - Last Name:RYUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1434 N LUCY MONTGOMERY WAY
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66061-6706
Mailing Address - Country:US
Mailing Address - Phone:913-242-5181
Mailing Address - Fax:
Practice Address - Street 1:1434 N LUCY MONTGOMERY WAY
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-6706
Practice Address - Country:US
Practice Address - Phone:913-242-5181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-25
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1811089014103K00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty