MEDICARE: JESSICA ANN MAIN RBT-18-61027

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
1	106S00000X	Behavior Technician	18-61027	MI

General Provider Information

NPI Number	:	1518444330
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA ANN MAIN RBT-18-61027

Provider Business Mailing Address
First Line	:	1900 VIKING CIR
Second Line	:
City	:	COMMERCE TWP
State	:	MI
Zip	:	48390-1578
Country	:	US
Telephone Number	:	248-767-4846
Fax Number	:

Provider Business Practice Location Address
First Line	:	1900 VIKING CIR
Second Line	:
City	:	COMMERCE TWP
State	:	MI
Zip	:	48390-1578
Country	:	US
Telephone Number	:	248-767-4846
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/24/2018
Last Update Date	:	07/24/2018

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