Provider Demographics
NPI:1134660459
Name:BOSTICK, JESSICA (BCBA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BOSTICK
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5703 BAY RD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48604-2507
Mailing Address - Country:US
Mailing Address - Phone:989-941-3730
Mailing Address - Fax:231-943-1334
Practice Address - Street 1:5815 BAY RD
Practice Address - Street 2:600
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-2542
Practice Address - Country:US
Practice Address - Phone:989-941-3730
Practice Address - Fax:231-943-1334
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-20
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI1-21-48132103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician