Provider Demographics
NPI:1710496336
Name:ITALIANO, JESSICA (BCBA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:ITALIANO
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 1:508 N ALEXANDER AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-1990
Mailing Address - Country:US
Mailing Address - Phone:586-921-3698
Mailing Address - Fax:
Practice Address - Street 1:4180 S A ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-6055
Practice Address - Country:US
Practice Address - Phone:317-222-1242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-26
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7401001804103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst