Provider Demographics
NPI:1235020702
Name:IVY, JACKSON JEFFERY
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:JEFFERY
Last Name:IVY
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 1:3013 OYSTER BAY AVE
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-2636
Mailing Address - Country:US
Mailing Address - Phone:512-809-3109
Mailing Address - Fax:
Practice Address - Street 1:3013 OYSTER BAY AVE
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-2636
Practice Address - Country:US
Practice Address - Phone:512-809-3109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-14
Last Update Date:2025-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst