Provider Demographics
NPI:1194461020
Name:BEVIS, JILLIAN KING (BCBA, CTLBA)
Entity Type:Individual
Prefix:MRS
First Name:JILLIAN
Middle Name:KING
Last Name:BEVIS
Suffix:
Gender:F
Credentials:BCBA, CTLBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 21
Mailing Address - Street 2:
Mailing Address - City:MIDDLEFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06455-0021
Mailing Address - Country:US
Mailing Address - Phone:203-213-3773
Mailing Address - Fax:
Practice Address - Street 1:54 RIDGE RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:CT
Practice Address - Zip Code:06422-3414
Practice Address - Country:US
Practice Address - Phone:203-213-3773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-12
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst