Provider Demographics
NPI:1356864367
Name:ANDERSON, JAMIE RAE (BCBA)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:RAE
Last Name:ANDERSON
Suffix:
Gender:F
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:N27W23953 PAUL RD STE 206
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-6244
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:N27W23953 PAUL RD STE 206
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-6244
Practice Address - Country:US
Practice Address - Phone:262-347-0701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-21
Last Update Date:2017-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI187-140103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst