Healthcare Provider Details

I. General information

NPI: 1588960256
Provider Name (Legal Business Name): JENNIFER ANNE JOHNSTON BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2011
Last Update Date: 01/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 POLK ST
GREENWOOD IN
46143-1623
US

IV. Provider business mailing address

360 POLK ST
GREENWOOD IN
46143-1623
US

V. Phone/Fax

Practice location:
  • Phone: 317-888-1557
  • Fax: 317-888-1571
Mailing address:
  • Phone: 317-888-1557
  • Fax: 317-888-1571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number01-03-1204
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: