=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275425167
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAQUALA BERRY
-----------------------------------------------------
Gender |
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2025
-----------------------------------------------------
Last Update Date | 07/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16414 SOUTHPARK DR
-----------------------------------------------------
City | WESTFIELD
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46074-8396
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-815-5501
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1905 E BALSAM CT
-----------------------------------------------------
City | ANDERSON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46011-2708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------