Provider Demographics
NPI:1346739539
Name:BRENNAN, JENNIFER (BCBA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BRENNAN
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 1:1402 SE NORTH BALCOURT CT
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7810
Mailing Address - Country:US
Mailing Address - Phone:407-383-6534
Mailing Address - Fax:772-209-6900
Practice Address - Street 1:821 SE OCEAN BLVD STE BANDC
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2456
Practice Address - Country:US
Practice Address - Phone:772-872-6940
Practice Address - Fax:772-209-6900
Is Sole Proprietor?:No
Enumeration Date:2018-05-03
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTRBT-18-47697106S00000X
FL1-21-52253103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102329500Medicaid