Provider Demographics
NPI:1164014817
Name:CHASSE, JESSICA (BCBA MED)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:CHASSE
Suffix:
Gender:F
Credentials:BCBA MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 CAMBRIA AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-2830
Mailing Address - Country:US
Mailing Address - Phone:860-884-9065
Mailing Address - Fax:
Practice Address - Street 1:705 N MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-1412
Practice Address - Country:US
Practice Address - Phone:860-233-3033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-04
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3175985103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT3175985OtherCT DPH