Provider Demographics
NPI:1588935258
Name:JACKSON, CARRIE RAE (MS, BCBA)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:RAE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10715 BABCOCK BLVD
Mailing Address - Street 2:
Mailing Address - City:GIBSONIA
Mailing Address - State:PA
Mailing Address - Zip Code:15044-8977
Mailing Address - Country:US
Mailing Address - Phone:412-498-9128
Mailing Address - Fax:724-502-4510
Practice Address - Street 1:10715 BABCOCK BLVD
Practice Address - Street 2:
Practice Address - City:GIBSONIA
Practice Address - State:PA
Practice Address - Zip Code:15044-8977
Practice Address - Country:US
Practice Address - Phone:412-498-9128
Practice Address - Fax:724-502-4510
Is Sole Proprietor?:No
Enumeration Date:2012-01-26
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1-05-2589103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral