Healthcare Provider Details

I. General information

NPI: 1679190649
Provider Name (Legal Business Name): JAC'QUES JAVAUGHN MONTGOMERY BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MISS JAC'QUES JAVAUGHN FARGO

II. Dates (important events)

Enumeration Date: 06/25/2020
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 S GREEN ST OFC F
TUPELO MS
38804-4901
US

IV. Provider business mailing address

395 CLARK ST
PONTOTOC MS
38863-8014
US

V. Phone/Fax

Practice location:
  • Phone: 757-800-9077
  • Fax:
Mailing address:
  • Phone: 757-800-9077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-26-2840053
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: