Healthcare Provider Details

I. General information

NPI: 1154901551
Provider Name (Legal Business Name): JACQUE ELLIOTT DEWALT BCBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2021
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8656 F ST
OMAHA NE
68127-1639
US

IV. Provider business mailing address

2718 N 118TH ST APT 333
OMAHA NE
68164-9680
US

V. Phone/Fax

Practice location:
  • Phone: 402-252-1363
  • Fax:
Mailing address:
  • Phone: 808-868-7765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0429
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: