Provider Demographics
NPI:1689418873
Name:DEVLIN, JACKSON
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:
Last Name:DEVLIN
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 1:316 EAGLES CT
Mailing Address - Street 2:
Mailing Address - City:TROPHY CLUB
Mailing Address - State:TX
Mailing Address - Zip Code:76262-5614
Mailing Address - Country:US
Mailing Address - Phone:817-901-4132
Mailing Address - Fax:
Practice Address - Street 1:2104 GREENBRIAR DR
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-8355
Practice Address - Country:US
Practice Address - Phone:817-984-8655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-21
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician