Provider Demographics
NPI:1184044323
Name:EDWARDS, JAKE CAMRON (BCBA)
Entity type:Individual
Prefix:MR
First Name:JAKE
Middle Name:CAMRON
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:M
Other - Last Name:EDWARDS-RICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:343 JERICHO RD
Mailing Address - Street 2:UNIT B
Mailing Address - City:RICHMOND
Mailing Address - State:VT
Mailing Address - Zip Code:05477-9173
Mailing Address - Country:US
Mailing Address - Phone:802-734-5642
Mailing Address - Fax:
Practice Address - Street 1:37 TALCOTT RD
Practice Address - Street 2:SUITE 114
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-2094
Practice Address - Country:US
Practice Address - Phone:802-662-7831
Practice Address - Fax:802-662-7834
Is Sole Proprietor?:No
Enumeration Date:2014-04-25
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT1141598103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst