Provider Demographics
NPI:1053883637
Name:JEWETT, VICTORYA (BCBA)
Entity type:Individual
Prefix:
First Name:VICTORYA
Middle Name:
Last Name:JEWETT
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 N VERDUGO RD STE 201
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-3207
Mailing Address - Country:US
Mailing Address - Phone:213-278-0500
Mailing Address - Fax:
Practice Address - Street 1:1555 N VERDUGO RD STE 201
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208-3207
Practice Address - Country:US
Practice Address - Phone:213-278-0500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-20
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA91781781DMedicaid