Provider Demographics
NPI:1659855849
Name:HUMPHREY, JACLYN RENEE (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:RENEE
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:RENEE
Other - Last Name:CHAPLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6402 W VERNAL PIKE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-9662
Mailing Address - Country:US
Mailing Address - Phone:812-320-9879
Mailing Address - Fax:
Practice Address - Street 1:1501 W TAPP RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-3459
Practice Address - Country:US
Practice Address - Phone:812-330-4460
Practice Address - Fax:812-330-4461
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
IN1-18-31655103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst