Provider Demographics
NPI:1346834611
Name:WHALLEY, JAIME (RBT)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:
Last Name:WHALLEY
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 STONEWALL AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-8837
Mailing Address - Country:US
Mailing Address - Phone:765-427-9943
Mailing Address - Fax:
Practice Address - Street 1:113G N MARINE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540-6508
Practice Address - Country:US
Practice Address - Phone:910-389-0901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-26
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCRBT21-157464106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty