Provider Demographics
NPI:1245848001
Name:LOCKWOOD WILLOUGHBY, JESSIE
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:LOCKWOOD WILLOUGHBY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2632 FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-4756
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2632 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-4756
Practice Address - Country:US
Practice Address - Phone:307-723-2520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-17
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYRBT-20-128053106S00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYRBT-20-128053OtherBACB