Provider Demographics
NPI:1316448251
Name:BANAAG, JHELLIES M (RBT, SPECIALIST)
Entity type:Individual
Prefix:
First Name:JHELLIES
Middle Name:M
Last Name:BANAAG
Suffix:
Gender:F
Credentials:RBT, SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8648 FESTIVAL DR
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-4570
Mailing Address - Country:US
Mailing Address - Phone:916-385-3203
Mailing Address - Fax:
Practice Address - Street 1:2291 W MARCH LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6652
Practice Address - Country:US
Practice Address - Phone:916-745-8211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16-15140106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty