Provider Demographics
NPI:1306287966
Name:JACKSON, CAROL ANNE (BCBA)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:ANNE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:437 WOODWAY DR
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-3354
Mailing Address - Country:US
Mailing Address - Phone:972-762-9916
Mailing Address - Fax:
Practice Address - Street 1:1410 14TH ST
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75074-6302
Practice Address - Country:US
Practice Address - Phone:214-650-6708
Practice Address - Fax:972-424-2333
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-11
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-12-12323103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst