Provider Demographics
NPI:1508614405
Name:JACK, BRIANNA LYNN (MA,BCBA,LBA)
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:LYNN
Last Name:JACK
Suffix:
Gender:F
Credentials:MA,BCBA,LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 N DOBSON RD STE F-2
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-9611
Mailing Address - Country:US
Mailing Address - Phone:480-722-1300
Mailing Address - Fax:
Practice Address - Street 1:3200 N DOBSON RD STE F-2
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-9611
Practice Address - Country:US
Practice Address - Phone:480-722-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-07
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBEH001466103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst