MEDICARE: JESSICA MALLILO

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	103K00000X	Behavior Analyst	LBA00533

General Provider Information

NPI Number	:	1972960300
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA MALLILO

Provider Business Mailing Address
First Line	:	13 SUSAN CIR
Second Line	:
City	:	JOHNSTON
State	:	RI
Zip	:	02919-6419
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	13 SUSAN CIR
Second Line	:
City	:	JOHNSTON
State	:	RI
Zip	:	02919-6419
Country	:	US
Telephone Number	:	401-391-7856
Fax Number	:

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

Provider Enumeration Date	:	01/15/2016
Last Update Date	:	03/11/2026

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Directions to “ JESSICA MALLILO ” Practice Location

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