Healthcare Provider Details

I. General information

NPI: 1679304950
Provider Name (Legal Business Name): JENNIFER MAE WHITEHALL BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2024
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 W TORRANCE BLVD STE 100
REDONDO BEACH CA
90277-3600
US

IV. Provider business mailing address

1023 OCEAN PARK BLVD APT 10
SANTA MONICA CA
90405-3974
US

V. Phone/Fax

Practice location:
  • Phone: 310-374-3300
  • Fax:
Mailing address:
  • Phone: 617-756-6964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-24-71621
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: