Provider Demographics
NPI:1861139032
Name:JACKSON, HEAVEN
Entity type:Individual
Prefix:
First Name:HEAVEN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325N ST PAUL ST
Mailing Address - Street 2:SUITE 3100
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201
Mailing Address - Country:US
Mailing Address - Phone:717-701-2241
Mailing Address - Fax:
Practice Address - Street 1:325N ST PAUL ST
Practice Address - Street 2:SUITE 3100
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75201
Practice Address - Country:US
Practice Address - Phone:717-701-2241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-18
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-22-215644106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician