Healthcare Provider Details

I. General information

NPI: 1598261257
Provider Name (Legal Business Name): JENNIFER KOUNTZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 04/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5465 ABLE CT
MOBILE AL
36693-3100
US

IV. Provider business mailing address

5451 ABLE CT
MOBILE AL
36693-3100
US

V. Phone/Fax

Practice location:
  • Phone: 251-640-4420
  • Fax:
Mailing address:
  • Phone: 251-649-4420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number2018-009
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: