Provider Demographics
NPI:1740829159
Name:JUSTICE, JESSICA DAWN (MA, BCBA, LBA (KY))
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:DAWN
Last Name:JUSTICE
Suffix:
Gender:F
Credentials:MA, BCBA, LBA (KY)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:632 EASTERN BLVD
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47129-2463
Mailing Address - Country:US
Mailing Address - Phone:812-725-9025
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:632 EASTERN BLVD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47129-2463
Practice Address - Country:US
Practice Address - Phone:812-725-9025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-02
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-17-34988106S00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
RBT-17-34988OtherRBT CERTIFICATE