Provider Demographics
NPI:1104166776
Name:JACKSON AUTISM CENTER
Entity type:Organization
Organization Name:JACKSON AUTISM CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIOR INTERVENTIONIST
Authorized Official - Prefix:DR
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:MULLICAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:769-218-9596
Mailing Address - Street 1:314 COLONIAL CIR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-4213
Mailing Address - Country:US
Mailing Address - Phone:769-218-9596
Mailing Address - Fax:
Practice Address - Street 1:314 COLONIAL CIR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-4213
Practice Address - Country:US
Practice Address - Phone:769-218-9596
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-19
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
No252Y00000XAgenciesEarly Intervention Provider AgencyGroup - Single Specialty