MEDICARE: JACOB DANIEL STRACENER BA

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-18-67467	CA
2	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1609342344
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB DANIEL STRACENER BA

Provider Business Mailing Address
First Line	:	535 WOODLAWN AVE APT 27
Second Line	:
City	:	CHULA VISTA
State	:	CA
Zip	:	91910-5140
Country	:	US
Telephone Number	:	619-730-9118
Fax Number	:

Provider Business Practice Location Address
First Line	:	8303 CLAIREMONT MESA BLVD STE 201202
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92111-1326
Country	:	US
Telephone Number	:	949-401-0619
Fax Number	:

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

Provider Enumeration Date	:	10/20/2018
Last Update Date	:	07/27/2023

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