MEDICARE: JODI LENNON BCABA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	0-24-15434	SC

General Provider Information

NPI Number	:	1356171151
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JODI LENNON BCABA

Provider Business Mailing Address
First Line	:	142 VILLA GRANDE ST UNIT E
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29579-9267
Country	:	US
Telephone Number	:	631-335-2090
Fax Number	:

Provider Business Practice Location Address
First Line	:	2952 LITTLE BETHEL RD
Second Line	:
City	:	GREEN SEA
State	:	SC
Zip	:	29545-3729
Country	:	US
Telephone Number	:	843-733-2184
Fax Number	:	843-894-3610

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/06/2024
Last Update Date	:	08/06/2024

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Directions to “ JODI LENNON BCABA” Practice Location

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