Provider Demographics
NPI:1306453790
Name:MADELINE, JACQUELINE JOANNE (BA, RBT)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:JOANNE
Last Name:MADELINE
Suffix:
Gender:F
Credentials:BA, RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27777 INKSTER RD STE 100
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-5312
Mailing Address - Country:US
Mailing Address - Phone:248-436-4400
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:7770 E WRIGHTSTOWN RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85715-4330
Practice Address - Country:US
Practice Address - Phone:888-975-4557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-29
Last Update Date:2025-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRBT-19-100316106S00000X
IN1-25-81243103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician