Provider Demographics
NPI:1891318986
Name:THWEATT-BURTON, JACQUELINE (BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:THWEATT-BURTON
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 1:708 BROAD AVE
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-1350
Mailing Address - Country:US
Mailing Address - Phone:251-648-4346
Mailing Address - Fax:228-300-2113
Practice Address - Street 1:530 SCARCE CREEK RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:TN
Practice Address - Zip Code:38351-8561
Practice Address - Country:US
Practice Address - Phone:731-614-3101
Practice Address - Fax:228-300-2113
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-22
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06888361Medicaid