Provider Demographics
NPI:1215571724
Name:VANNARATH, JENNIFER R
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:VANNARATH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 W LAWRENCE LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85051-3661
Mailing Address - Country:US
Mailing Address - Phone:602-525-7384
Mailing Address - Fax:
Practice Address - Street 1:3201 W PEORIA AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-4608
Practice Address - Country:US
Practice Address - Phone:602-926-7200
Practice Address - Fax:602-368-2730
Is Sole Proprietor?:No
Enumeration Date:2019-10-29
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBEH-000852103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst