Provider Demographics
NPI:1083848386
Name:SULLIVAN, JENNIFER (BCBA)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:SULLIVAN
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 1:160 WINDSOR AVE
Mailing Address - Street 2:
Mailing Address - City:SWAMPSCOTT
Mailing Address - State:MA
Mailing Address - Zip Code:01907-1048
Mailing Address - Country:US
Mailing Address - Phone:339-440-5058
Mailing Address - Fax:
Practice Address - Street 1:160 WINDSOR AVE
Practice Address - Street 2:
Practice Address - City:SWAMPSCOTT
Practice Address - State:MA
Practice Address - Zip Code:01907-1048
Practice Address - Country:US
Practice Address - Phone:339-440-5058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-14
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1084533103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst