MEDICARE: MRS. JESSICA LACHELLE REVIES RBT

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-23-254721	VA

General Provider Information

NPI Number	:	1750096947
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JESSICA LACHELLE REVIES RBT

Provider Business Mailing Address
First Line	:	400 SABAL PALM LN APT 102
Second Line	:
City	:	CHESAPEAKE
State	:	VA
Zip	:	23320-1739
Country	:	US
Telephone Number	:	757-323-2784
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 SABAL PALM LN APT 102
Second Line	:
City	:	CHESAPEAKE
State	:	VA
Zip	:	23320-1739
Country	:	US
Telephone Number	:	757-323-2784
Fax Number	:

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

Provider Enumeration Date	:	01/23/2023
Last Update Date	:	01/23/2023

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