Healthcare Provider Details

I. General information

NPI: 1043901242
Provider Name (Legal Business Name): JENNIFER SHONER RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2023
Last Update Date: 05/17/2023
Certification Date: 05/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

298 MEDLEY CT
VINE GROVE KY
40175-8421
US

IV. Provider business mailing address

539 HILLCREST DR
RADCLIFF KY
40160-2801
US

V. Phone/Fax

Practice location:
  • Phone: 270-352-1133
  • Fax:
Mailing address:
  • Phone: 517-262-0802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBACB831051
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: