Healthcare Provider Details

I. General information

NPI: 1700017498
Provider Name (Legal Business Name): JENNIFER BROOKE HENNESSEY ED.D., LPE, BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2009
Last Update Date: 12/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 COURT ST STE 1
CONWAY AR
72032-5417
US

IV. Provider business mailing address

5 TROXELL LN
CONWAY AR
72034-9311
US

V. Phone/Fax

Practice location:
  • Phone: 501-940-4435
  • Fax:
Mailing address:
  • Phone: 501-513-9007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number99-5E
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: