Individual
CHERELLE TELITA MONTRICE JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
8811 S TACOMA WAY STE 204, LAKEWOOD, WA 98499-4595
(612) 702-4861
Mailing address
16522 39TH AVE E, TACOMA, WA 98446-1644
(253) 254-2462
Taxonomy
Speciality
Code
Description
License number
State
103K00000X
Behavior Analyst
—
—
106S00000X
Behavior Technician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1427613306
TECH
WA
Enumeration date
05/06/2019
Last updated
12/01/2020
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