Provider Demographics
NPI:1518444330
Name:MAIN, JESSICA ANN (RBT-18-61027)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN
Last Name:MAIN
Suffix:
Gender:F
Credentials:RBT-18-61027
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 VIKING CIR
Mailing Address - Street 2:
Mailing Address - City:COMMERCE TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48390-1578
Mailing Address - Country:US
Mailing Address - Phone:248-767-4846
Mailing Address - Fax:
Practice Address - Street 1:1900 VIKING CIR
Practice Address - Street 2:
Practice Address - City:COMMERCE TWP
Practice Address - State:MI
Practice Address - Zip Code:48390-1578
Practice Address - Country:US
Practice Address - Phone:248-767-4846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI18-61027106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician