Provider Demographics
NPI:1780080069
Name:BURRIESCI, JACQUELYN (BCBA)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:BURRIESCI
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:
Other - Last Name:SHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:101 N MARAGRET CT
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23692-2275
Mailing Address - Country:US
Mailing Address - Phone:570-766-9652
Mailing Address - Fax:
Practice Address - Street 1:12727 MCMANUS BLVD
Practice Address - Street 2:STE G
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-2360
Practice Address - Country:US
Practice Address - Phone:757-869-4162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-13
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133000414103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst