Provider Demographics
NPI:1215118567
Name:GUTIERREZ, JACLYN (BCBA)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:GUTIERREZ
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 1:4054 N PAULINA ST APT 2S
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-2574
Mailing Address - Country:US
Mailing Address - Phone:440-452-8046
Mailing Address - Fax:773-539-8099
Practice Address - Street 1:4801 W PETERSON AVE
Practice Address - Street 2:SUITE 512
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-5713
Practice Address - Country:US
Practice Address - Phone:773-539-7099
Practice Address - Fax:773-539-8099
Is Sole Proprietor?:No
Enumeration Date:2007-11-15
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-12-12623103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH08258Medicaid