Provider Demographics
NPI:1588247217
Name:JACKSON, ALYSSA RAE
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:RAE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:ALYSSA
Other - Middle Name:RAE
Other - Last Name:THORNHILL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:428 THORNHILL LN
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38351-8116
Mailing Address - Country:US
Mailing Address - Phone:731-798-8244
Mailing Address - Fax:
Practice Address - Street 1:428 THORNHILL LN
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:TN
Practice Address - Zip Code:38351-8116
Practice Address - Country:US
Practice Address - Phone:731-798-8244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-30
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician