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NPI Code Detail

MEDICARE: JASMINE MALLARD

MEDICARE: JASMINE MALLARD
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
1103K00000XBehavior Analyst1-21-52124
2106S00000XBehavior Technician

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1RBT-18-74281OTHERBACB REGISTRATION NUMBER

General Provider Information

NPI Number : 1699233908
Entity Type Code : Individual
Provider Name (Legal Business Name) : JASMINE MALLARD
Provider Business Mailing Address
First Line : 600 N JACKSON ST STE 203
Second Line :
City : MEDIA
State : PA
Zip : 19063-2574
Country : US
Telephone Number : 484-444-2285
Fax Number :
Provider Business Practice Location Address
First Line : 700 ABBOTT DR STE 2
Second Line :
City : BROOMALL
State : PA
Zip : 19008-4323
Country : US
Telephone Number : 484-995-6547
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/05/2019
Last Update Date : 08/16/2021

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Directions to “ JASMINE MALLARD ” Practice Location

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