Provider Demographics
NPI:1932545449
Name:JACKSON, KEVIN D (BCBA-D)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:M
Credentials:BCBA-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4060 OLD PLANTATION LOOP
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32311-1306
Mailing Address - Country:US
Mailing Address - Phone:352-225-7115
Mailing Address - Fax:
Practice Address - Street 1:4060 OLD PLANTATION LOOP
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32311-1306
Practice Address - Country:US
Practice Address - Phone:352-225-7115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-13
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst