Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103K00000X | Behavior Analyst |
NPI | 1003277997 |
---|---|
Provider Name | Rick Jackson |
First Address | Phoenix, AZ 85085-6087 |
Second Address | Phoenix, AZ 85085-6087 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/03/2016 |
Last Update Date | 19/03/2016 |