MEDICARE: JESSIE LOCKWOOD WILLOUGHBY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	RBT-20-128053	WY
2	103K00000X	Behavior Analyst

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	RBT-20-128053	OTHER	WY	BACB

General Provider Information

NPI Number	:	1245848001
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSIE LOCKWOOD WILLOUGHBY

Provider Business Mailing Address
First Line	:	2632 FOOTHILL BLVD
Second Line	:
City	:	ROCK SPRINGS
State	:	WY
Zip	:	82901-4756
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2632 FOOTHILL BLVD
Second Line	:
City	:	ROCK SPRINGS
State	:	WY
Zip	:	82901-4756
Country	:	US
Telephone Number	:	307-723-2520
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2020
Last Update Date	:	04/13/2022

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Directions to “ JESSIE LOCKWOOD WILLOUGHBY ” Practice Location

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