Provider Demographics
NPI:1558724211
Name:SHAMBLIN, JEANNE HEATH (BCBA)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:HEATH
Last Name:SHAMBLIN
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 1:30 ROBIN HOOD RD
Mailing Address - Street 2:
Mailing Address - City:DRY PRONG
Mailing Address - State:LA
Mailing Address - Zip Code:71423-3548
Mailing Address - Country:US
Mailing Address - Phone:318-625-5345
Mailing Address - Fax:
Practice Address - Street 1:30 ROBIN HOOD RD
Practice Address - Street 2:
Practice Address - City:DRY PRONG
Practice Address - State:LA
Practice Address - Zip Code:71423-3548
Practice Address - Country:US
Practice Address - Phone:318-625-5345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL-112103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst