Provider Demographics
NPI:1073393948
Name:KNOWLES, JESSICA LYN (RBT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYN
Last Name:KNOWLES
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5480 ARDENNES WAY
Mailing Address - Street 2:
Mailing Address - City:STANSBURY PARK
Mailing Address - State:UT
Mailing Address - Zip Code:84074-8057
Mailing Address - Country:US
Mailing Address - Phone:435-849-0645
Mailing Address - Fax:
Practice Address - Street 1:8031 S 700 E
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-0555
Practice Address - Country:US
Practice Address - Phone:385-695-2203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-29
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTBACB974958106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician