Healthcare Provider Details

I. General information

NPI: 1972080372
Provider Name (Legal Business Name): LISA GAIL JONES BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2018
Last Update Date: 07/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17390 DUGDALE DR
SOUTH BEND IN
46635-1512
US

IV. Provider business mailing address

3500 DEPAUW BLVD STE 3070
INDIANAPOLIS IN
46268-6135
US

V. Phone/Fax

Practice location:
  • Phone: 574-400-2169
  • Fax: 765-450-6664
Mailing address:
  • Phone: 317-449-4833
  • Fax: 765-450-6664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: