Provider Demographics
NPI:1912540113
Name:WEEMS, JACQUELINE (BCBA)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
Last Name:WEEMS
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 1:6520 DOUBLE EAGLE DR UNIT 309
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-1571
Mailing Address - Country:US
Mailing Address - Phone:708-466-1082
Mailing Address - Fax:
Practice Address - Street 1:6520 DOUBLE EAGLE DR UNIT 309
Practice Address - Street 2:
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-1571
Practice Address - Country:US
Practice Address - Phone:708-466-1082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-21
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-19-34520103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst