Provider Demographics
NPI:1649028143
Name:JACKSON, KHALIYAH (RBT)
Entity type:Individual
Prefix:
First Name:KHALIYAH
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5663 LIBERTY CREEK DR E
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-1004
Mailing Address - Country:US
Mailing Address - Phone:317-652-9460
Mailing Address - Fax:
Practice Address - Street 1:9905 FALL CREEK RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-4804
Practice Address - Country:US
Practice Address - Phone:317-813-4690
Practice Address - Fax:317-845-1886
Is Sole Proprietor?:No
Enumeration Date:2024-05-09
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-23-271743106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician