Provider Demographics
NPI:1477191401
Name:VAN DYKE, JACOB ALEXANDER (MA, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:ALEXANDER
Last Name:VAN DYKE
Suffix:
Gender:M
Credentials:MA, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:175 MARKET PLACE DR STE A
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40229-4471
Practice Address - Country:US
Practice Address - Phone:502-251-7002
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2019-12-20
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-19-102036106S00000X
KY278031103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
RBT-19-102036OtherRBT CERTIFICATE
1-22-595-49OtherBCBA CERTIFICATE