Healthcare Provider Details

I. General information

NPI: 1134739238
Provider Name (Legal Business Name): JESSICA A ZICCARELLI BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2020
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date: 08/08/2024
Reactivation Date: 06/03/2026

III. Provider practice location address

16730 LEE ST
ORLAND PARK IL
60467-8709
US

IV. Provider business mailing address

807 82ND ST UNIT 14
KENOSHA WI
53143-6121
US

V. Phone/Fax

Practice location:
  • Phone: 708-575-1567
  • Fax:
Mailing address:
  • Phone: 262-721-8292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-24-73658
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: