Healthcare Provider Details

I. General information

NPI: 1346814886
Provider Name (Legal Business Name): ALANNA JACQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2021
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 ALFRED DR STE A
CLARKSVILLE TN
37043-4426
US

IV. Provider business mailing address

130 ALFRED DR STE A
CLARKSVILLE TN
37043-4426
US

V. Phone/Fax

Practice location:
  • Phone: 931-503-7010
  • Fax:
Mailing address:
  • Phone: 931-503-7010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number65
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-25-16107
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: