Provider Demographics
NPI:1053072579
Name:JACKSON, TAYLOR (RBT)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 CHRISTIAN CT
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:GA
Mailing Address - Zip Code:30228-2890
Mailing Address - Country:US
Mailing Address - Phone:470-737-5755
Mailing Address - Fax:470-878-2946
Practice Address - Street 1:990 BEAR CREEK BLVD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:GA
Practice Address - Zip Code:30228-1864
Practice Address - Country:US
Practice Address - Phone:470-878-1177
Practice Address - Fax:470-878-2946
Is Sole Proprietor?:No
Enumeration Date:2022-01-06
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
I-24-77829103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst