Provider Demographics
NPI:1942663406
Name:SULLIVAN, JACQUELINE (BCBA)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:SULLIVAN
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 1:7108 S KANNER HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7462
Mailing Address - Country:US
Mailing Address - Phone:855-832-6727
Mailing Address - Fax:772-675-9100
Practice Address - Street 1:1127 AUTUMN POINT CT
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-9030
Practice Address - Country:US
Practice Address - Phone:845-807-8825
Practice Address - Fax:904-538-0714
Is Sole Proprietor?:No
Enumeration Date:2016-04-01
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst