Provider Demographics
NPI:1215445267
Name:JAKUPCAK, ANNALISSA MARIE (MA BCBA)
Entity type:Individual
Prefix:
First Name:ANNALISSA
Middle Name:MARIE
Last Name:JAKUPCAK
Suffix:
Gender:F
Credentials:MA BCBA
Other - Prefix:
Other - First Name:ANNALISSA
Other - Middle Name:MARIE
Other - Last Name:MCCLUAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6160 TUTT BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80923-3503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6160 TUTT BLVD STE 120
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80923-3503
Practice Address - Country:US
Practice Address - Phone:719-540-2101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-11
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-17-28865103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst