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NPI Code Detail

MEDICARE: JAKE ROBERT KELSO BCBA

MEDICARE: JAKE ROBERT KELSO BCBA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1106S00000XBehavior Technician106S00000XCA
2103K00000XBehavior Analyst1-24-75663CA

General Provider Information

NPI Number : 1356084388
Entity Type Code : Individual
Provider Name (Legal Business Name) : JAKE ROBERT KELSO BCBA
Provider Business Mailing Address
First Line : 501 W BROADWAY STE 800
Second Line :
City : SAN DIEGO
State : CA
Zip : 92101-3546
Country : US
Telephone Number : 855-832-6727
Fax Number : 772-675-9100
Provider Business Practice Location Address
First Line : 501 W BROADWAY STE 800
Second Line :
City : SAN DIEGO
State : CA
Zip : 92101-3546
Country : US
Telephone Number : 855-832-6729
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/18/2022
Last Update Date : 05/29/2026

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