Provider Demographics
NPI:1508651829
Name:JACKSON, SHAWNEE (RBT)
Entity type:Individual
Prefix:MR
First Name:SHAWNEE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5221 6TH STREET FRONTAGE RD E
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-5190
Mailing Address - Country:US
Mailing Address - Phone:217-292-1983
Mailing Address - Fax:217-614-4092
Practice Address - Street 1:5221 6TH STREET FRONTAGE RD E
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-5190
Practice Address - Country:US
Practice Address - Phone:217-292-1983
Practice Address - Fax:217-614-4092
Is Sole Proprietor?:No
Enumeration Date:2025-04-09
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-25-427194106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician