Provider Demographics
NPI:1669817060
Name:WISWELL, JACQUE (BCBA)
Entity Type:Individual
Prefix:
First Name:JACQUE
Middle Name:
Last Name:WISWELL
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:JACQUE
Other - Middle Name:
Other - Last Name:RABINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:635 S SHELTON ST
Mailing Address - Street 2:UNIT C
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91506-3157
Mailing Address - Country:US
Mailing Address - Phone:209-607-0830
Mailing Address - Fax:
Practice Address - Street 1:370 W SIERRA MADRE BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:SIERRA MADRE
Practice Address - State:CA
Practice Address - Zip Code:91024-2354
Practice Address - Country:US
Practice Address - Phone:626-355-5160
Practice Address - Fax:626-355-5173
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-30
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11212147103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst