Provider Demographics
NPI:1902522733
Name:DEPTAWA, JARRED (MA, LBA, BCBA)
Entity Type:Individual
Prefix:
First Name:JARRED
Middle Name:
Last Name:DEPTAWA
Suffix:
Gender:M
Credentials:MA, LBA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2885 MABE RD APT 2210
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78251-1582
Mailing Address - Country:US
Mailing Address - Phone:210-313-6424
Mailing Address - Fax:
Practice Address - Street 1:6051 FM 3009 STE 215
Practice Address - Street 2:
Practice Address - City:SCHERTZ
Practice Address - State:TX
Practice Address - Zip Code:78154-3473
Practice Address - Country:US
Practice Address - Phone:830-420-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-13
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
1-23-69336103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician