Healthcare Provider Details

I. General information

NPI: 1467373613
Provider Name (Legal Business Name): JACK BWEWUSA
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 QUINCE ORCHARD RD STE 205
GAITHERSBURG MD
20878-1435
US

IV. Provider business mailing address

7108 S KANNER HWY
STUART FL
34997-7462
US

V. Phone/Fax

Practice location:
  • Phone: 855-832-6727
  • Fax:
Mailing address:
  • Phone: 772-349-6317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number106E00000X
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: