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NPI Code Detail

MEDICARE: JACQUELYN WICKERHAM RBT

MEDICARE: JACQUELYN WICKERHAM 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
1106S00000XBehavior Technician15-04762GA

General Provider Information

NPI Number : 1821506668
Entity Type Code : Individual
Provider Name (Legal Business Name) : JACQUELYN WICKERHAM RBT
Provider Business Mailing Address
First Line : 6100 VETERANS PKWY STE 11
Second Line :
City : COLUMBUS
State : GA
Zip : 31909-3514
Country : US
Telephone Number : 706-221-8966
Fax Number :
Provider Business Practice Location Address
First Line : 6100 VETERANS PKWY STE 11
Second Line :
City : COLUMBUS
State : GA
Zip : 31909-3514
Country : US
Telephone Number : 706-221-8966
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/15/2018
Last Update Date : 01/15/2018

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Directions to “ JACQUELYN WICKERHAM RBT” Practice Location

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