Provider Demographics
NPI:1205367208
Name:IBRAHIM, JAD JR (BCBA)
Entity Type:Individual
Prefix:
First Name:JAD
Middle Name:
Last Name:IBRAHIM
Suffix:JR
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 1:7801 RICHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22153-2318
Mailing Address - Country:US
Mailing Address - Phone:703-509-2517
Mailing Address - Fax:
Practice Address - Street 1:7801 RICHFIELD RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22153-2318
Practice Address - Country:US
Practice Address - Phone:703-509-2517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-22
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-19-40291103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst