Healthcare Provider Details

I. General information

NPI: 1093044190
Provider Name (Legal Business Name): JESSE S ANDERSON BCBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2009
Last Update Date: 06/05/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 W LANCASTER AVE STE 205
FORT WORTH TX
76102-3499
US

IV. Provider business mailing address

1300 W LANCASTER AVE STE 205
FORT WORTH TX
76102-3410
US

V. Phone/Fax

Practice location:
  • Phone: 682-303-9200
  • Fax: 682-303-9239
Mailing address:
  • Phone: 682-303-9200
  • Fax: 682-303-9239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1052
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: