Provider Demographics
NPI:1669759478
Name:JACKS, STEPHEN ERIK (MS, BCBA)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:ERIK
Last Name:JACKS
Suffix:
Gender:M
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 DEWART ST.
Mailing Address - Street 2:PO BOX 86
Mailing Address - City:RIVERSIDE
Mailing Address - State:PA
Mailing Address - Zip Code:17868-0086
Mailing Address - Country:US
Mailing Address - Phone:570-204-6154
Mailing Address - Fax:
Practice Address - Street 1:216 DEWART ST.
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:PA
Practice Address - Zip Code:17868-0086
Practice Address - Country:US
Practice Address - Phone:570-204-6154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst