Provider Demographics
NPI:1730500299
Name:CUSAAC, JACQUELINE ANDERSON
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANDERSON
Last Name:CUSAAC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11085 HARBOUR SPRINGS CIR
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33428-1244
Mailing Address - Country:US
Mailing Address - Phone:561-445-9220
Mailing Address - Fax:
Practice Address - Street 1:11085 HARBOUR SPRINGS CIR
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33428-1244
Practice Address - Country:US
Practice Address - Phone:561-445-9220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-30
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst