Provider Demographics
NPI:1174015994
Name:FARA, JACQUELYN ROSE (RBT-16-19382)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:ROSE
Last Name:FARA
Suffix:
Gender:F
Credentials:RBT-16-19382
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1707 S 5TH PL
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-4324
Mailing Address - Country:US
Mailing Address - Phone:630-335-9962
Mailing Address - Fax:
Practice Address - Street 1:1707 S 5TH PL
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-4324
Practice Address - Country:US
Practice Address - Phone:630-335-9962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-06
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-16-19382106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician