Provider Demographics
NPI:1427426782
Name:MARTIN, JONAH DANIEL (BCBA)
Entity type:Individual
Prefix:
First Name:JONAH
Middle Name:DANIEL
Last Name:MARTIN
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 58
Mailing Address - Street 2:405 WEST WARD
Mailing Address - City:ENERGY
Mailing Address - State:IL
Mailing Address - Zip Code:62933-0058
Mailing Address - Country:US
Mailing Address - Phone:618-534-0315
Mailing Address - Fax:
Practice Address - Street 1:900 ROYAL HEIGHTS RD
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5457
Practice Address - Country:US
Practice Address - Phone:314-560-7063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-03
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-09-5883103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-09-5883OtherBEHAVIOR ANALYST CERTIFICATION BOARD