Provider Demographics
NPI:1679713754
Name:WALLACE, JASON D (BCBA)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:D
Last Name:WALLACE
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 SHOREVIEW LN
Mailing Address - Street 2:
Mailing Address - City:OLDSMAR
Mailing Address - State:FL
Mailing Address - Zip Code:34677-4106
Mailing Address - Country:US
Mailing Address - Phone:813-546-9867
Mailing Address - Fax:813-818-0510
Practice Address - Street 1:104 SHOREVIEW LN
Practice Address - Street 2:
Practice Address - City:OLDSMAR
Practice Address - State:FL
Practice Address - Zip Code:34677-4106
Practice Address - Country:US
Practice Address - Phone:813-546-9867
Practice Address - Fax:813-818-0510
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-02
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-04-1845103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst