Provider Demographics
NPI:1558808170
Name:MINTON, JESSICA (BCBA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MINTON
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 1:1477 FAUBUSH RD
Mailing Address - Street 2:
Mailing Address - City:NANCY
Mailing Address - State:KY
Mailing Address - Zip Code:42544-6582
Mailing Address - Country:US
Mailing Address - Phone:606-677-2636
Mailing Address - Fax:606-677-0412
Practice Address - Street 1:1477 FAUBUSH RD
Practice Address - Street 2:
Practice Address - City:NANCY
Practice Address - State:KY
Practice Address - Zip Code:42544-6582
Practice Address - Country:US
Practice Address - Phone:606-677-2636
Practice Address - Fax:606-677-0412
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-20
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY170518103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst