Provider Demographics
NPI:1932869955
Name:REVORD, JESSICA (BCBA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:REVORD
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 1:4640 CAPITAL DR
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33463-8183
Mailing Address - Country:US
Mailing Address - Phone:954-895-9862
Mailing Address - Fax:
Practice Address - Street 1:2500 N MILITARY TRL STE 304
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-6324
Practice Address - Country:US
Practice Address - Phone:561-421-5111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-20
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-22-58706103K00000X
FL0-21-13157106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst