Healthcare Provider Details

I. General information

NPI: 1700430956
Provider Name (Legal Business Name): JACK GRAVES BCBA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2019
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 E SUMNER AVE
INDIANAPOLIS IN
46237-1209
US

IV. Provider business mailing address

3650 E SUMNER AVE
INDIANAPOLIS IN
46237-1209
US

V. Phone/Fax

Practice location:
  • Phone: 812-205-9219
  • Fax:
Mailing address:
  • Phone: 812-205-9219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBACB365678
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: