Provider Demographics
NPI:1003222977
Name:TONNA, JACOB EDWARD
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:EDWARD
Last Name:TONNA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JACOB
Other - Middle Name:
Other - Last Name:TONNA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:M ED BCBA # 1-21-52
Mailing Address - Street 1:7108 S KANNER HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7462
Mailing Address - Country:US
Mailing Address - Phone:855-832-6727
Mailing Address - Fax:
Practice Address - Street 1:1000 GOEGLEIN GULCH RD UNIT 1121
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7924
Practice Address - Country:US
Practice Address - Phone:941-979-7924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-10
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
FL1-21-52065103K00000X
CO1-21-52065103K00000X
NM1-21-52065103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst