Provider Demographics
NPI:1073881389
Name:TRAVIS, JENNIE L (BCBA)
Entity Type:Individual
Prefix:MISS
First Name:JENNIE
Middle Name:L
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5326 TAMARIND LN
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96818-7083
Mailing Address - Country:US
Mailing Address - Phone:517-899-8632
Mailing Address - Fax:
Practice Address - Street 1:100 KAHELU AVE STE 112
Practice Address - Street 2:
Practice Address - City:MILILANI
Practice Address - State:HI
Practice Address - Zip Code:96789-3913
Practice Address - Country:US
Practice Address - Phone:808-625-3000
Practice Address - Fax:808-625-3006
Is Sole Proprietor?:No
Enumeration Date:2011-12-01
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-11-8945103K00000X
MI103K00000X
HIBA-495103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst