Provider Demographics
NPI:1447658414
Name:LATSHAW, JESSICA (BCBA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LATSHAW
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5805 OAKWOOD DR
Mailing Address - Street 2:APT. E
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-2932
Mailing Address - Country:US
Mailing Address - Phone:815-354-8419
Mailing Address - Fax:
Practice Address - Street 1:5805 OAKWOOD DR
Practice Address - Street 2:APT. E
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-2932
Practice Address - Country:US
Practice Address - Phone:815-354-8419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-08
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-14-16765103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst