Provider Demographics
NPI:1720470933
Name:BURNS, JACKALYNNE (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:JACKALYNNE
Middle Name:
Last Name:BURNS
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:JACKALYNNE
Other - Middle Name:J
Other - Last Name:DELONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, BCBA
Mailing Address - Street 1:PO BOX 623
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:FL
Mailing Address - Zip Code:33576-0623
Mailing Address - Country:US
Mailing Address - Phone:352-999-0447
Mailing Address - Fax:352-437-4921
Practice Address - Street 1:11820 MUNBURY DR
Practice Address - Street 2:
Practice Address - City:DADE CITY
Practice Address - State:FL
Practice Address - Zip Code:33525
Practice Address - Country:US
Practice Address - Phone:352-999-0447
Practice Address - Fax:352-437-4921
Is Sole Proprietor?:No
Enumeration Date:2015-02-25
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017556800Medicaid