Provider Demographics
NPI:1003650201
Name:JACKSON, THAON KAY
Entity type:Individual
Prefix:
First Name:THAON
Middle Name:KAY
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7940 BANCROFT AVE APT 8
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94605-3267
Mailing Address - Country:US
Mailing Address - Phone:510-565-9025
Mailing Address - Fax:
Practice Address - Street 1:7940 BANCROFT AVE APT 8
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94605-3267
Practice Address - Country:US
Practice Address - Phone:510-565-9025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-21
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician