Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 106S00000X | Behavior Technician | 18-73992 | MI |
NPI | 1003389693 |
---|---|
Provider Name | Jessica Blair |
First Address | Northbrook, IL 60062-8005 |
Second Address | Northbrook, IL 60062-8005 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/01/2019 |
Last Update Date | 07/01/2019 |