Provider Demographics
NPI:1366123838
Name:JACKSON, GWEN D (RBT)
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:GWENDOLYN
Other - Middle Name:D
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RBT
Mailing Address - Street 1:330 W EDMOND RD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-5600
Mailing Address - Country:US
Mailing Address - Phone:405-216-3391
Mailing Address - Fax:405-216-3391
Practice Address - Street 1:330 W EDMOND RD
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-5600
Practice Address - Country:US
Practice Address - Phone:405-216-3391
Practice Address - Fax:405-216-3391
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-27
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-22-251702106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician