Provider Demographics
NPI:1093132516
Name:JEWELL, CARLEY ANNE (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:CARLEY
Middle Name:ANNE
Last Name:JEWELL
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6268 REDINGTON CT SE
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-9065
Mailing Address - Country:US
Mailing Address - Phone:616-485-0178
Mailing Address - Fax:
Practice Address - Street 1:7086 8TH AVE
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428-9352
Practice Address - Country:US
Practice Address - Phone:616-667-9551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-21
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-12-11615103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst