Healthcare Provider Details

I. General information

NPI: 1821892704
Provider Name (Legal Business Name): JENNIE GRACE MADDEN BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2025
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 TURNBERRY WAY
PINEHURST NC
28374-8508
US

IV. Provider business mailing address

3464 LEWIS LOOP RD SE
BOLIVIA NC
28422-7560
US

V. Phone/Fax

Practice location:
  • Phone: 704-440-3580
  • Fax:
Mailing address:
  • Phone: 910-789-0258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-25-80377
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: