Healthcare Provider Details

I. General information

NPI: 1467004143
Provider Name (Legal Business Name): JESSICA ANN MYERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2019
Last Update Date: 09/14/2022
Certification Date: 09/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2299 WOODBURY AVE
NEWINGTON NH
03801-7854
US

IV. Provider business mailing address

360 ROUTE 101 STE 11
BEDFORD NH
03110-5031
US

V. Phone/Fax

Practice location:
  • Phone: 603-294-0649
  • Fax:
Mailing address:
  • Phone: 603-471-2522
  • Fax: 877-754-5246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-22-58357
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: