Individual
TYLA JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
70 WOOD ST APT 22, PAWTUCKET, RI 02860
(161) 751-6777
Mailing address
70 WOOD ST APT 22, PAWTUCKET, RI 02860-3123
(161) 751-6777
Taxonomy
Speciality
Code
Description
License number
State
106S00000X
Behavior Technician
—
—
171M00000X
Case Manager/Care Coordinator
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1346589215
APPLIED BEHAVIORAL INTERVENTIONS
—
Enumeration date
06/12/2018
Last updated
12/11/2020
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