1891318986 NPI number — JACQUELINE THWEATT-BURTON BCBA, LBA

Table of content: JACQUELINE THWEATT-BURTON BCBA, LBA (NPI 1891318986)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891318986 NPI number — JACQUELINE THWEATT-BURTON BCBA, LBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THWEATT-BURTON
Provider First Name:
JACQUELINE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BCBA, LBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891318986
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
708 BROAD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GULFPORT
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39501-1350
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-648-4346
Provider Business Mailing Address Fax Number:
228-300-2113

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
530 SCARCE CREEK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38351-8561
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-614-3101
Provider Business Practice Location Address Fax Number:
228-300-2113
Provider Enumeration Date:
05/22/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 06888361 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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