Provider Demographics
NPI:1487073292
Name:VERMILLION, JODI LYNN (MA, BCBA)
Entity type:Individual
Prefix:MRS
First Name:JODI
Middle Name:LYNN
Last Name:VERMILLION
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:MRS
Other - First Name:JODI
Other - Middle Name:LYNN
Other - Last Name:DIEKEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, BCBA
Mailing Address - Street 1:706 OGLESBY AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-6430
Mailing Address - Country:US
Mailing Address - Phone:309-481-5177
Mailing Address - Fax:
Practice Address - Street 1:706 OGLESBY AVE STE 200
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-6430
Practice Address - Country:US
Practice Address - Phone:309-585-2857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-08
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1- 17- 25430103K00000X
IL0-14-5920103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst