Provider Demographics
NPI:1801489174
Name:JACK, ALLISON KAY (BCABA)
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:KAY
Last Name:JACK
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
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Mailing Address - Street 1:1824 TOUBY PIKE STE B
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46901-2573
Mailing Address - Country:US
Mailing Address - Phone:765-628-7400
Mailing Address - Fax:855-940-0177
Practice Address - Street 1:7230 ENGLE RD STE 102
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-2234
Practice Address - Country:US
Practice Address - Phone:260-373-1050
Practice Address - Fax:260-471-0285
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-17
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst