MEDICARE: JACQULYN HEREDIA 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-26-506526

General Provider Information

NPI Number	:	1891652889
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQULYN HEREDIA RBT

Provider Business Mailing Address
First Line	:	16255 VENTURA BLVD STE 900
Second Line	:
City	:	ENCINO
State	:	CA
Zip	:	91436-2317
Country	:	US
Telephone Number	:	803-335-0718
Fax Number	:	801-316-3564

Provider Business Practice Location Address
First Line	:	200 SPRINGTREE DR STE 100
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29223-8614
Country	:	US
Telephone Number	:	803-335-0718
Fax Number	:

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

Provider Enumeration Date	:	01/09/2026
Last Update Date	:	01/09/2026

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Directions to “ JACQULYN HEREDIA RBT” Practice Location

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