Provider Demographics
NPI:1487046645
Name:LABRIE, JILLIAN K (MA, BCBA)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:K
Last Name:LABRIE
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 MARGARET AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6242
Mailing Address - Country:US
Mailing Address - Phone:530-318-0824
Mailing Address - Fax:833-220-8663
Practice Address - Street 1:1105 MARGARET AVE
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-6242
Practice Address - Country:US
Practice Address - Phone:530-318-0824
Practice Address - Fax:833-220-8663
Is Sole Proprietor?:No
Enumeration Date:2015-02-25
Last Update Date:2021-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-13-15031103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst