Provider Demographics
NPI:1215101035
Name:SHORT, JAMIE L (MS, BCBA)
Entity type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:L
Last Name:SHORT
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1560 LAUREL LEDGE DR
Mailing Address - Street 2:
Mailing Address - City:LA VERGNE
Mailing Address - State:TN
Mailing Address - Zip Code:37086-4185
Mailing Address - Country:US
Mailing Address - Phone:901-870-7053
Mailing Address - Fax:
Practice Address - Street 1:1560 LAUREL LEDGE DR
Practice Address - Street 2:
Practice Address - City:LA VERGNE
Practice Address - State:TN
Practice Address - Zip Code:37086-4185
Practice Address - Country:US
Practice Address - Phone:901-870-7053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-14
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1517394Medicaid