Healthcare Provider Details

I. General information

NPI: 1154837664
Provider Name (Legal Business Name): JESSICA L YOUNG BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2017
Last Update Date: 10/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 BRADLEY RD
SEVERN MD
21144-2786
US

IV. Provider business mailing address

PO BOX 164
SEVERN MD
21144-0164
US

V. Phone/Fax

Practice location:
  • Phone: 301-346-5394
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberLBA517
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: