Provider Demographics
NPI:1093223703
Name:JACK, BENJAMIN RYAN (BCBA)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:RYAN
Last Name:JACK
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 TEN ROD RD STE C201
Mailing Address - Street 2:BUILDING C SUITE 201
Mailing Address - City:NORTH KINGSTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02852-4171
Mailing Address - Country:US
Mailing Address - Phone:401-294-3990
Mailing Address - Fax:
Practice Address - Street 1:1130 TEN ROD RD STE 201
Practice Address - Street 2:
Practice Address - City:NORTH KINGSTOWN
Practice Address - State:RI
Practice Address - Zip Code:02852-4161
Practice Address - Country:US
Practice Address - Phone:401-294-3990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-16
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI1-17-28975103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst