=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306643614
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHANIE JAMISON RBT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2025
-----------------------------------------------------
Last Update Date | 02/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8401 OHIO
-----------------------------------------------------
City | MERRILLVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46410-6687
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-525-4572
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6600 LIGHTHOUSE DR APT 101
-----------------------------------------------------
City | PORTAGE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46368-6923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-381-6001
-----------------------------------------------------
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 | RBT-22-206391
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------