=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629577754
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNA MARIE ABRAHAMSON M.ED., BCBA, COBA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2018
-----------------------------------------------------
Last Update Date | 12/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6460 CENTERVILLE BUSINESS PKWY
-----------------------------------------------------
City | CENTERVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45459-2633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-265-8151
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1117 WESTOVER RD
-----------------------------------------------------
City | XENIA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45385-9063
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 146-448-8846
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | COBA.00503
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------