Provider Demographics
NPI:1740786367
Name:NILAND, JESSICA ANN (RBT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN
Last Name:NILAND
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 MILLBRANCH RD STE 1200
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-1594
Mailing Address - Country:US
Mailing Address - Phone:601-255-5264
Mailing Address - Fax:
Practice Address - Street 1:9230 OLD LORRAINE RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-6059
Practice Address - Country:US
Practice Address - Phone:228-313-6808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician