Provider Demographics
NPI:1356711766
Name:IDICULA, JERRY GEORGE (MED, BCBA)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:GEORGE
Last Name:IDICULA
Suffix:
Gender:M
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1332 MARYLAND ST
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48230-1006
Mailing Address - Country:US
Mailing Address - Phone:313-288-9458
Mailing Address - Fax:
Practice Address - Street 1:1332 MARYLAND ST
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE PARK
Practice Address - State:MI
Practice Address - Zip Code:48230
Practice Address - Country:US
Practice Address - Phone:313-288-9458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-28
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1-19-34854103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst