Provider Demographics
NPI:1174141600
Name:ZDANAVICIUS, JACQUELINE DENIESE (MA, BCBA)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:DENIESE
Last Name:ZDANAVICIUS
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:DENIESE
Other - Last Name:KOLHOUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS, BCBA
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:2222 POSHARD DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47203-1843
Practice Address - Country:US
Practice Address - Phone:812-302-4750
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2020-07-10
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-21-51380103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst