Provider Demographics
NPI:1750123220
Name:JACKSON, CHRISTIAN WILLIAM
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:WILLIAM
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 1:10544 HIGHWAY 36 APT 3322
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014-4125
Mailing Address - Country:US
Mailing Address - Phone:864-586-9468
Mailing Address - Fax:
Practice Address - Street 1:1130 HURRICANE SHOALS RD NE STE 1800
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-4849
Practice Address - Country:US
Practice Address - Phone:470-740-0355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-06
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician