Healthcare Provider Details

I. General information

NPI: 1760887509
Provider Name (Legal Business Name): JESSICA L KIETUR MA, BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2014
Last Update Date: 06/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29691 6 MILE RD STE 100D
LIVONIA MI
48152
US

IV. Provider business mailing address

29691 6 MILE RD STE 100D
LIVONIA MI
48152-8606
US

V. Phone/Fax

Practice location:
  • Phone: 313-986-3588
  • Fax:
Mailing address:
  • Phone: 313-986-3588
  • Fax:

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: