Provider Demographics
NPI:1396528758
Name:SHIRLEY, JEWEL LYNNE (BCBA)
Entity type:Individual
Prefix:
First Name:JEWEL
Middle Name:LYNNE
Last Name:SHIRLEY
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2221 ALAMUCHA WHYNOT RD
Mailing Address - Street 2:
Mailing Address - City:TOOMSUBA
Mailing Address - State:MS
Mailing Address - Zip Code:39364-8703
Mailing Address - Country:US
Mailing Address - Phone:601-616-1585
Mailing Address - Fax:
Practice Address - Street 1:6301 HIGHWAY 39
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39305-9400
Practice Address - Country:US
Practice Address - Phone:601-812-8368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSBACB771243103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst