Healthcare Provider Details

I. General information

NPI: 1265349443
Provider Name (Legal Business Name): JESSICA GUSTAFSON MA., BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 SPRING FOREST RD STE 206
RALEIGH NC
27616-2812
US

IV. Provider business mailing address

4614 RIVERWOOD CIR APT 1109 APT 1109
RALEIGH NC
27612-5783
US

V. Phone/Fax

Practice location:
  • Phone: 919-457-4453
  • Fax:
Mailing address:
  • Phone: 732-484-0358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: