Provider Demographics
NPI:1760887509
Name:KIETUR, JESSICA L (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:KIETUR
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29691 6 MILE RD STE 100D
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-8606
Mailing Address - Country:US
Mailing Address - Phone:313-986-3588
Mailing Address - Fax:
Practice Address - Street 1:29691 6 MILE RD STE 100D
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152
Practice Address - Country:US
Practice Address - Phone:313-986-3588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-22
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
MI6301015858103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst