Healthcare Provider Details

I. General information

NPI: 1841783925
Provider Name (Legal Business Name): JESICA PETERSON BCBA, LBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2018
Last Update Date: 01/06/2022
Certification Date: 01/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3121 N OAK STREET EXT
VALDOSTA GA
31602-1099
US

IV. Provider business mailing address

406 JACKSON CIR
LAKE PARK GA
31636-4928
US

V. Phone/Fax

Practice location:
  • Phone: 800-832-9419
  • Fax:
Mailing address:
  • Phone: 229-630-2086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-20-44103
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number18-57850
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: