Basic Information
| Provider Information | |||||||||
| NPI: | 1568000537 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TREVOR | ||||||||
| FirstName: | JACQUELYN | ||||||||
| MiddleName: | ANN | ||||||||
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| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MASELLA | ||||||||
| OtherFirstName: | JACQUELYN | ||||||||
| OtherMiddleName: | ANN | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1133 HAPPY RIDGE DR | ||||||||
| Address2: | |||||||||
| City: | FRONT ROYAL | ||||||||
| State: | VA | ||||||||
| PostalCode: | 226305302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5406922802 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 120 BELLVIEW AVE | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 226013142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5405420200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2019 | ||||||||
| LastUpdateDate: | 12/20/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/20/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.