Provider Demographics
NPI:1427604917
Name:DIXON, JACLYN MICHELE (MED, LBS, BCBA)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:MICHELE
Last Name:DIXON
Suffix:
Gender:F
Credentials:MED, LBS, BCBA
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:MICHELE
Other - Last Name:RADCLIFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:136 TRADEWIND RD
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:PA
Mailing Address - Zip Code:16102-2705
Mailing Address - Country:US
Mailing Address - Phone:855-400-3455
Mailing Address - Fax:
Practice Address - Street 1:136 TRADEWIND RD
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:PA
Practice Address - Zip Code:16102-2705
Practice Address - Country:US
Practice Address - Phone:855-400-3455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-12
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARBT-17-44763106S00000X
PA1-21-46986103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
106S00000XOtherPRIVATE INSURANCE