Provider Demographics
NPI:1427613306
Name:JACKSON, CHERELLE TELITA MONTRICE
Entity type:Individual
Prefix:
First Name:CHERELLE
Middle Name:TELITA MONTRICE
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 1:16522 39TH AVE E
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98446-1644
Mailing Address - Country:US
Mailing Address - Phone:253-254-2462
Mailing Address - Fax:
Practice Address - Street 1:8811 S TACOMA WAY STE 204
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-4595
Practice Address - Country:US
Practice Address - Phone:612-702-4861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-06
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1427613306OtherTECH