Provider Demographics
NPI:1487162145
Name:BLICKENSTAFF, JACQUELYN JACKY (BCBA)
Entity type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:JACKY
Last Name:BLICKENSTAFF
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 1:619 PAOPUA LOOP
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-3535
Mailing Address - Country:US
Mailing Address - Phone:714-615-9697
Mailing Address - Fax:
Practice Address - Street 1:111 HEKILI ST STE A406
Practice Address - Street 2:
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-2800
Practice Address - Country:US
Practice Address - Phone:808-489-3548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-16
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-19-38676103K00000X
HI335103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst