Healthcare Provider Details

I. General information

NPI: 1225923956
Provider Name (Legal Business Name): TRINITY JADE CISSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2025
Last Update Date: 06/11/2025
Certification Date: 06/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

870 CORPORATE DR STE 104
LEXINGTON KY
40503-5417
US

IV. Provider business mailing address

870 CORPORATE DR STE 104
LEXINGTON KY
40503-5417
US

V. Phone/Fax

Practice location:
  • Phone: 859-785-1441
  • Fax:
Mailing address:
  • Phone: 859-785-1441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-435470
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: