Healthcare Provider Details

I. General information

NPI: 1477034833
Provider Name (Legal Business Name): JENNIFER JOHANTGEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2018
Last Update Date: 09/26/2023
Certification Date: 09/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 CENTRE POINT CIR STE 108
NAPERVILLE IL
60563-9364
US

IV. Provider business mailing address

1840 CENTRE POINT CIR STE 108
NAPERVILLE IL
60563-9364
US

V. Phone/Fax

Practice location:
  • Phone: 331-207-1818
  • Fax:
Mailing address:
  • Phone: 331-207-1818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-23-68089
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-18-63659
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: