Provider Demographics
NPI:1386151348
Name:OBREGON, JESSICA (RBT-17-38811)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:OBREGON
Suffix:
Gender:F
Credentials:RBT-17-38811
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4760 BURGER RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44121-3831
Mailing Address - Country:US
Mailing Address - Phone:419-307-0805
Mailing Address - Fax:
Practice Address - Street 1:24865 DETROIT RD
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-2512
Practice Address - Country:US
Practice Address - Phone:440-641-1170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-29
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-17-38811106S00000X
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician