Healthcare Provider Details

I. General information

NPI: 1982326724
Provider Name (Legal Business Name): JENNA ROSE BROCK MA, BCBA, LBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2022
Last Update Date: 07/14/2025
Certification Date: 07/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2537 LARKIN RD
LEXINGTON KY
40503-3201
US

IV. Provider business mailing address

2537 LARKIN RD
LEXINGTON KY
40503-3201
US

V. Phone/Fax

Practice location:
  • Phone: 859-406-5699
  • Fax:
Mailing address:
  • Phone: 859-406-5699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number300329
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-22-212220
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: