Provider Demographics
NPI:1053898916
Name:JACKSON, INGRID (RBT, CHW, CHT)
Entity type:Individual
Prefix:
First Name:INGRID
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RBT, CHW, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7261 W CHARLESTON BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-1679
Mailing Address - Country:US
Mailing Address - Phone:702-396-0101
Mailing Address - Fax:702-215-5801
Practice Address - Street 1:7261 W CHARLESTON BLVD STE 101
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-1679
Practice Address - Country:US
Practice Address - Phone:702-396-0101
Practice Address - Fax:702-222-0212
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-24
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NV25728486251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No251S00000XAgenciesCommunity/Behavioral Health