Healthcare Provider Details

I. General information

NPI: 1922783489
Provider Name (Legal Business Name): JAQUELA DADE RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2023
Last Update Date: 06/21/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 TUTOR LN STE 107
EVANSVILLE IN
47715-7295
US

IV. Provider business mailing address

821 TAYLOR AVE
EVANSVILLE IN
47713-2671
US

V. Phone/Fax

Practice location:
  • Phone: 812-602-1038
  • Fax:
Mailing address:
  • Phone: 412-712-5693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-279684
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: