Provider Demographics
NPI:1639786916
Name:MOZLEY, JACQUELINE MADISON (RBT)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MADISON
Last Name:MOZLEY
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 OLDE TOWN WAY
Mailing Address - Street 2:
Mailing Address - City:ROCKMART
Mailing Address - State:GA
Mailing Address - Zip Code:30153-7455
Mailing Address - Country:US
Mailing Address - Phone:678-896-3440
Mailing Address - Fax:
Practice Address - Street 1:225 CEDAR HILL ST STE 200
Practice Address - Street 2:
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752-5900
Practice Address - Country:US
Practice Address - Phone:678-896-3440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-20-136713106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician