Provider Demographics
NPI:1376434548
Name:KEITH JACKSON, TATIONNA SANAI
Entity type:Individual
Prefix:
First Name:TATIONNA
Middle Name:SANAI
Last Name:KEITH 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 1:476 ROGERS ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32811-1763
Mailing Address - Country:US
Mailing Address - Phone:407-719-4022
Mailing Address - Fax:
Practice Address - Street 1:730 SAND LAKE RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-7750
Practice Address - Country:US
Practice Address - Phone:407-412-6114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-14
Last Update Date:2025-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-25-452898106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician