MEDICARE: JESSICA LYNN GOOD RBT

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	RBT-20-121754	IN

General Provider Information

NPI Number	:	1538774351
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA LYNN GOOD RBT

Provider Business Mailing Address
First Line	:	3500 DEPAUW BLVD STE 3070
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46268-6135
Country	:	US
Telephone Number	:	855-324-0885
Fax Number	:	317-520-8200

Provider Business Practice Location Address
First Line	:	1558 E BOULEVARD STE A
Second Line	:
City	:	KOKOMO
State	:	IN
Zip	:	46902-2587
Country	:	US
Telephone Number	:	765-252-0530
Fax Number	:	317-520-8200

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

Provider Enumeration Date	:	09/09/2020
Last Update Date	:	09/09/2020

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