Provider Demographics
NPI:1912767609
Name:JACKSON, ELIJAH
Entity Type:Individual
Prefix:
First Name:ELIJAH
Middle Name:
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 1:9038 CROSS PARK DR STE 105
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-4729
Mailing Address - Country:US
Mailing Address - Phone:865-394-6612
Mailing Address - Fax:865-315-7014
Practice Address - Street 1:9038 CROSS PARK DR STE 105
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4729
Practice Address - Country:US
Practice Address - Phone:865-394-6612
Practice Address - Fax:865-315-7014
Is Sole Proprietor?:No
Enumeration Date:2024-03-20
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRBT-24-327052106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician