Healthcare Provider Details

I. General information

NPI: 1477215523
Provider Name (Legal Business Name): JALA MERSHA FAULKS RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2021
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3095 KETTERING BLVD
MORAINE OH
45439-1983
US

IV. Provider business mailing address

2570 TECHNICAL DR
MIAMISBURG OH
45342-6107
US

V. Phone/Fax

Practice location:
  • Phone: 937-293-8300
  • Fax:
Mailing address:
  • Phone: 937-847-8750
  • Fax: 937-847-8753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-21-192347
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: