Provider Demographics
NPI:1184365959
Name:JACKSON, BRANDON NICHOLAS
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:NICHOLAS
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 1:16587 ENTERPRISE DR STE E
Mailing Address - Street 2:
Mailing Address - City:THREE RIVERS
Mailing Address - State:MI
Mailing Address - Zip Code:49093-7902
Mailing Address - Country:US
Mailing Address - Phone:213-864-1870
Mailing Address - Fax:
Practice Address - Street 1:16587 ENTERPRISE DR STE E
Practice Address - Street 2:
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093-7902
Practice Address - Country:US
Practice Address - Phone:213-864-1870
Practice Address - Fax:269-421-0830
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician