Provider Demographics
NPI:1902579709
Name:MANGAN, JESSICA LYN (BCBA)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:LYN
Last Name:MANGAN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:30 RICH ST APT 23
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-7844
Mailing Address - Country:US
Mailing Address - Phone:617-833-2886
Mailing Address - Fax:
Practice Address - Street 1:100 SYLVAN RD STE G700
Practice Address - Street 2:
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-1817
Practice Address - Country:US
Practice Address - Phone:781-569-5111
Practice Address - Fax:781-569-5112
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-28
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA39158103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA39158OtherLICENSE