Healthcare Provider Details

I. General information

NPI: 1659855849
Provider Name (Legal Business Name): JACLYN RENEE HUMPHREY MA, BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACLYN RENEE CHAPLIN

II. Dates (important events)

Enumeration Date: 09/24/2018
Last Update Date: 02/06/2023
Certification Date: 02/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 W TAPP RD
BLOOMINGTON IN
47403-3459
US

IV. Provider business mailing address

6402 W VERNAL PIKE
BLOOMINGTON IN
47404-9662
US

V. Phone/Fax

Practice location:
  • Phone: 812-330-4460
  • Fax: 812-330-4461
Mailing address:
  • Phone: 812-320-9879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-18-31655
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: