Healthcare Provider Details

I. General information

NPI: 1114309903
Provider Name (Legal Business Name): JAN AIELLO PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2015
Last Update Date: 03/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3840 HULEN ST
FORT WORTH TX
76107-7277
US

IV. Provider business mailing address

1015 MCKINLEY ST
BENBROOK TX
76126-3427
US

V. Phone/Fax

Practice location:
  • Phone: 817-335-3022
  • Fax:
Mailing address:
  • Phone: 817-249-8100
  • Fax: 817-249-2215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-14-17271
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: