Provider Demographics
NPI:1033707153
Name:CHAN, JESSICA (MSED, BCBA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:MSED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4917 170TH ST
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-1012
Mailing Address - Country:US
Mailing Address - Phone:646-549-6291
Mailing Address - Fax:
Practice Address - Street 1:4917 170TH ST
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-1012
Practice Address - Country:US
Practice Address - Phone:646-549-6291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-05
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
BACB526371103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst