Provider Demographics
NPI:1861059487
Name:JACKSON, ANITA RIKKI (MSED, BCBA)
Entity type:Individual
Prefix:MS
First Name:ANITA
Middle Name:RIKKI
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14420 W SIDE BLVD APT 310
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-6271
Mailing Address - Country:US
Mailing Address - Phone:301-318-5429
Mailing Address - Fax:
Practice Address - Street 1:14420 W SIDE BLVD APT 310
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-6271
Practice Address - Country:US
Practice Address - Phone:301-318-5429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-20
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLBA612103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst