Provider Demographics
NPI:1790267201
Name:JACQUEZ, BROOKE (BCBA)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:JACQUEZ
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 1:700 N DOBSON RD UNIT 48
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-6974
Mailing Address - Country:US
Mailing Address - Phone:480-773-9786
Mailing Address - Fax:
Practice Address - Street 1:1166 S GILBERT RD
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-3460
Practice Address - Country:US
Practice Address - Phone:602-535-8341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1-22-61960103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst