Provider Demographics
NPI:1073026480
Name:MASON, JESSICA ANN (BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN
Last Name:MASON
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1363
Mailing Address - Street 2:
Mailing Address - City:WHITLEY CITY
Mailing Address - State:KY
Mailing Address - Zip Code:42653-1363
Mailing Address - Country:US
Mailing Address - Phone:606-516-2148
Mailing Address - Fax:
Practice Address - Street 1:1878 SANDHILL RD
Practice Address - Street 2:
Practice Address - City:WHITLEY CITY
Practice Address - State:KY
Practice Address - Zip Code:42653-4164
Practice Address - Country:US
Practice Address - Phone:606-516-2148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-07
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY175251103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY175251Medicaid