Provider Demographics
NPI:1972990034
Name:WALDERA, JERYN LEE (BCBA)
Entity Type:Individual
Prefix:
First Name:JERYN
Middle Name:LEE
Last Name:WALDERA
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 1:458 COULEE TRL
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-8156
Mailing Address - Country:US
Mailing Address - Phone:715-410-1182
Mailing Address - Fax:
Practice Address - Street 1:458 COULEE TRL
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-8156
Practice Address - Country:US
Practice Address - Phone:715-410-1182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-16
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-15-17917OtherBCBA CERTIFICATION