Basic Information
| Provider Information | |||||||||
| NPI: | 1023591047 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | RACHEL | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | BEHAVIOR ANALYST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11037 WARNER AVE # 339 | ||||||||
| Address2: | |||||||||
| City: | FOUNTAIN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927084007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148488319 | ||||||||
| FaxNumber: | 7145966274 | ||||||||
| Practice Location | |||||||||
| Address1: | 4949 SW MACADAM AVE # 30 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972393912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882734292 | ||||||||
| FaxNumber: | 8882933374 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2018 | ||||||||
| LastUpdateDate: | 12/22/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-18-53582 | CO | N | 103K00000X | ABA-B-10209046 | OR | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.