Provider Demographics
NPI:1841783925
Name:PETERSON, JESICA (BCBA, LBA)
Entity Type:Individual
Prefix:MRS
First Name:JESICA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 JACKSON CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:31636-4928
Mailing Address - Country:US
Mailing Address - Phone:229-630-2086
Mailing Address - Fax:
Practice Address - Street 1:3121 N OAK STREET EXT
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1099
Practice Address - Country:US
Practice Address - Phone:800-832-9419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-12
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT18-57850106S00000X
NM1-20-44103103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician