Provider Demographics
NPI:1386080927
Name:ETHEREDGE, JESSICA (MS, BCBA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:ETHEREDGE
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6232 SADDLE WOOD LN
Mailing Address - Street 2:
Mailing Address - City:FAIRHOPE
Mailing Address - State:AL
Mailing Address - Zip Code:36532-5557
Mailing Address - Country:US
Mailing Address - Phone:228-623-5454
Mailing Address - Fax:888-977-2153
Practice Address - Street 1:6232 SADDLE WOOD LN
Practice Address - Street 2:
Practice Address - City:FAIRHOPE
Practice Address - State:AL
Practice Address - Zip Code:36532-5557
Practice Address - Country:US
Practice Address - Phone:228-623-5454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-21
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2021-028103K00000X
TX1-09-6490103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst