Healthcare Provider Details

I. General information

NPI: 1982182705
Provider Name (Legal Business Name): JASEN WALLACE BCBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2018
Last Update Date: 05/10/2026
Certification Date: 05/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3437 DORMER AVE
CONCORD CA
94519-1603
US

IV. Provider business mailing address

625 ASHBURY ST APT 15
SAN FRANCISCO CA
94117-4703
US

V. Phone/Fax

Practice location:
  • Phone: 415-989-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-22-62688
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: