Provider Demographics
NPI:1972307528
Name:MAFFETT, JUWAN GORDON
Entity type:Individual
Prefix:
First Name:JUWAN
Middle Name:GORDON
Last Name:MAFFETT
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8398 MISSISSIPPI ST
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-6316
Mailing Address - Country:US
Mailing Address - Phone:219-755-4049
Mailing Address - Fax:
Practice Address - Street 1:8398 MISSISSIPPI ST
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-6316
Practice Address - Country:US
Practice Address - Phone:219-755-4049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-02
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-25-422579106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician