MEDICARE: MR. JEFFREY CHARLES ENZINNA BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	11-068-16

General Provider Information

NPI Number	:	1760726715
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JEFFREY CHARLES ENZINNA BCBA

Provider Business Mailing Address
First Line	:	1860 FM 359 RD # 238
Second Line	:
City	:	RICHMOND
State	:	TX
Zip	:	77406-1296
Country	:	US
Telephone Number	:	281-818-6408
Fax Number	:

Provider Business Practice Location Address
First Line	:	1860 FM 359 RD # 238
Second Line	:
City	:	RICHMOND
State	:	TX
Zip	:	77406-1296
Country	:	US
Telephone Number	:	281-818-6408
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2012
Last Update Date	:	11/15/2012

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