Healthcare Provider Details

I. General information

NPI: 1669011664
Provider Name (Legal Business Name): JESSICA MALDONADO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2019
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3623 CALVIN DR
COLUMBUS GA
31904-7915
US

IV. Provider business mailing address

3623 CALVIN DR
COLUMBUS GA
31904-7915
US

V. Phone/Fax

Practice location:
  • Phone: 706-940-5100
  • Fax: 762-208-7512
Mailing address:
  • Phone: 706-940-5100
  • Fax: 762-208-7512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: