Provider Demographics
NPI:1073948915
Name:THAXTON, JACQUELINE RICHELLE (BCBA)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:RICHELLE
Last Name:THAXTON
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3922 MEZZANINE DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-8642
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12726 HAMILTON CROSSING BLVD
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-5422
Practice Address - Country:US
Practice Address - Phone:317-249-2242
Practice Address - Fax:317-249-2248
Is Sole Proprietor?:No
Enumeration Date:2013-09-11
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-12-11897103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst