Healthcare Provider Details

I. General information

NPI: 1497096572
Provider Name (Legal Business Name): AMANDA JOSEPHINE JAKUBOWICZ BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2013
Last Update Date: 08/24/2021
Certification Date: 08/24/2021
Deactivation Date: 07/19/2021
Reactivation Date: 08/20/2021

III. Provider practice location address

203 S ELMER AVE
SAYRE PA
18840-2019
US

IV. Provider business mailing address

203 S ELMER AVE
SAYRE PA
18840-2019
US

V. Phone/Fax

Practice location:
  • Phone: 607-329-1235
  • Fax:
Mailing address:
  • Phone: 607-329-1235
  • Fax: 607-535-2666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: