MEDICARE: JACQUAN WHITE

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-20-131441	GA

General Provider Information

NPI Number	:	1841802998
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUAN WHITE

Provider Business Mailing Address
First Line	:	PO BOX 253
Second Line	:
City	:	SKILLMAN
State	:	NJ
Zip	:	08558-0253
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 TIMBER TRAIL RD STE 100
Second Line	:
City	:	RICHMOND HILL
State	:	GA
Zip	:	31324-9415
Country	:	US
Telephone Number	:	912-785-9027
Fax Number	:

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

Provider Enumeration Date	:	08/20/2020
Last Update Date	:	08/20/2020

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Directions to “ JACQUAN WHITE ” Practice Location

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