Provider Demographics
NPI:1669095105
Name:VILORIA, JERRICA CLAIRE (CBTCB61074441)
Entity type:Individual
Prefix:
First Name:JERRICA CLAIRE
Middle Name:
Last Name:VILORIA
Suffix:
Gender:F
Credentials:CBTCB61074441
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 NE 180TH ST APT 310
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98155-3881
Mailing Address - Country:US
Mailing Address - Phone:360-774-3139
Mailing Address - Fax:
Practice Address - Street 1:1221 NE 180TH ST APT 310
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98155-3881
Practice Address - Country:US
Practice Address - Phone:360-774-3139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-19
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACBT.CB.61074441106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA102054119WAMedicaid