Provider Demographics
NPI:1063988467
Name:JACKSON, BRITANY
Entity type:Individual
Prefix:
First Name:BRITANY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 MAIN ST APT B
Mailing Address - Street 2:
Mailing Address - City:BALDWINVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:01436-1107
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24 MAIN ST APT B
Practice Address - Street 2:
Practice Address - City:BALDWINVILLE
Practice Address - State:MA
Practice Address - Zip Code:01436-1107
Practice Address - Country:US
Practice Address - Phone:860-712-7626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician