Provider Demographics
NPI:1124651559
Name:FAY, JACOB PATRICK (BCBA)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:PATRICK
Last Name:FAY
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 1:3155 N COLLEGE AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-3500
Mailing Address - Country:US
Mailing Address - Phone:479-957-9121
Mailing Address - Fax:
Practice Address - Street 1:3155 N COLLEGE AVE STE 108
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-3500
Practice Address - Country:US
Practice Address - Phone:479-957-9121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-13
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1-21-53551103K00000X
ARRBT-19-85301106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARBACB495512OtherBACB ID