Provider Demographics
NPI:1962175448
Name:JACKSON, AARON M
Entity type:Individual
Prefix:
First Name:AARON
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11509 216TH ST APT 110
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90715-2518
Mailing Address - Country:US
Mailing Address - Phone:623-889-4678
Mailing Address - Fax:
Practice Address - Street 1:11509 216TH ST APT 110
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90715-2518
Practice Address - Country:US
Practice Address - Phone:623-889-4678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-29
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst