Healthcare Provider Details

I. General information

NPI: 1811459977
Provider Name (Legal Business Name): JEREMY MICHAEL EVANS M.S. BCBA, LBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2019
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 NATCHEZ TRACE AVE
BOWLING GREEN KY
42103-7940
US

IV. Provider business mailing address

165 NATCHEZ TRACE AVE
BOWLING GREEN KY
42103-7940
US

V. Phone/Fax

Practice location:
  • Phone: 270-715-8453
  • Fax:
Mailing address:
  • Phone: 270-715-8453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number307199
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: