Provider Demographics
NPI:1760983464
Name:LANG, JESICA (BCBA)
Entity Type:Individual
Prefix:
First Name:JESICA
Middle Name:
Last Name:LANG
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:PO BOX 767938
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-7938
Mailing Address - Country:US
Mailing Address - Phone:818-241-6780
Mailing Address - Fax:818-241-6853
Practice Address - Street 1:950A UNION RD STE 108
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-3432
Practice Address - Country:US
Practice Address - Phone:818-241-6780
Practice Address - Fax:818-241-6853
Is Sole Proprietor?:No
Enumeration Date:2018-02-27
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NY1-19-38088103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician