Provider Demographics
NPI:1316522071
Name:BLACK, JESSICA FUSCO (BCBA)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:FUSCO
Last Name:BLACK
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1360 MACKEY BRANCH DR
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-3225
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1360 MACKEY BRANCH DR
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-3225
Practice Address - Country:US
Practice Address - Phone:423-847-5749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-15
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1-21-48414103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN471201135Medicaid