Provider Demographics
NPI:1841013059
Name:JACKSON, BENJAMIN ADAM (RBT)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:ADAM
Last Name:JACKSON
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 ROSEBERRY CIR
Mailing Address - Street 2:
Mailing Address - City:PORT WENTWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:31407-5612
Mailing Address - Country:US
Mailing Address - Phone:904-767-1215
Mailing Address - Fax:
Practice Address - Street 1:100 COMMERCE CT
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-9445
Practice Address - Country:US
Practice Address - Phone:615-560-6622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-05
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician