Provider Demographics
NPI:1649833112
Name:BLOUGH, JESSICA LAUREN (MA, BCBA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LAUREN
Last Name:BLOUGH
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9400 S WINCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-6350
Mailing Address - Country:US
Mailing Address - Phone:773-316-3099
Mailing Address - Fax:
Practice Address - Street 1:19056 HENRY DR
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-9302
Practice Address - Country:US
Practice Address - Phone:708-995-5751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-19
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL11935455103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst