Provider Demographics
NPI:1336772573
Name:STOUT, JESSICA MAE (BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MAE
Last Name:STOUT
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 SW 89TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-8510
Mailing Address - Country:US
Mailing Address - Phone:206-618-4726
Mailing Address - Fax:
Practice Address - Street 1:24 SW 89TH ST APT 101
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-8510
Practice Address - Country:US
Practice Address - Phone:206-618-4726
Practice Address - Fax:540-898-1040
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-17
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133001578103K00000X
OK1-19-36386103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst