Provider Demographics
NPI:1326792201
Name:MOULD, JASON ANDREW (BCABA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:ANDREW
Last Name:MOULD
Suffix:
Gender:M
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9815 CROSS PINE CT
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-2367
Mailing Address - Country:US
Mailing Address - Phone:561-223-8076
Mailing Address - Fax:561-584-5372
Practice Address - Street 1:9815 CROSS PINE CT
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33467-2367
Practice Address - Country:US
Practice Address - Phone:561-223-8076
Practice Address - Fax:561-584-5372
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-09
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-108988106S00000X
106S00000X
FL0-23-14274106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105169200Medicaid