Provider Demographics
NPI:1790254753
Name:COIMBRA, JESSICA (MS, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:COIMBRA
Suffix:
Gender:F
Credentials:MS, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1728 EASTERN AVE APT 8
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21231-2452
Mailing Address - Country:US
Mailing Address - Phone:443-616-4170
Mailing Address - Fax:
Practice Address - Street 1:422 GILMOR RD
Practice Address - Street 2:
Practice Address - City:JOPPA
Practice Address - State:MD
Practice Address - Zip Code:21085-4219
Practice Address - Country:US
Practice Address - Phone:443-616-4170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-20
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-18-32079103K00000X
MDLBA504103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst