Provider Demographics
NPI:1013236645
Name:REVERE, JILL (BCBA)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:REVERE
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 1:1477 E 83RD AVE
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-6307
Mailing Address - Country:US
Mailing Address - Phone:219-472-0628
Mailing Address - Fax:219-750-9287
Practice Address - Street 1:1477 E 83RD AVE
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-6307
Practice Address - Country:US
Practice Address - Phone:219-472-0628
Practice Address - Fax:219-750-9287
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-21
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst