Provider Demographics
NPI:1558728816
Name:DETOMA, JANE KATHERINE (MA, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:KATHERINE
Last Name:DETOMA
Suffix:
Gender:F
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 1:2360 MURPHY BLVD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30504-6002
Practice Address - Country:US
Practice Address - Phone:770-535-8372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-18
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 103K00000X
KY240229103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-17-28561OtherBCBA CERTIFICATE