Provider Demographics
NPI:1396298113
Name:POWELL, JACOB EMERY (MS, BCBA, LBA)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:EMERY
Last Name:POWELL
Suffix:
Gender:M
Credentials:MS, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:1300 E NEW CIRCLE ROAD
Practice Address - Street 2:SUITE 150
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40505-9001
Practice Address - Country:US
Practice Address - Phone:859-685-1019
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2016-07-28
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY163670103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-15-18467OtherBCBA CERTIFICATE