Provider Demographics
NPI:1760614382
Name:JAMBA, AMY MICHELLE (BCBA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MICHELLE
Last Name:JAMBA
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 1:1490 QUARTERPATH RD
Mailing Address - Street 2:SUITE 5A-310
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185-6544
Mailing Address - Country:US
Mailing Address - Phone:310-940-8853
Mailing Address - Fax:
Practice Address - Street 1:1317 JAMESTOWN RD
Practice Address - Street 2:SUITE 102-B
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-3364
Practice Address - Country:US
Practice Address - Phone:310-940-8853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-14
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133000146103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA542057784OtherTAX ID- FAMILY PRIORITY, LLC