Provider Demographics
NPI:1376856344
Name:DOHERTY, JENNIFER L (BCBA)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:L
Last Name:DOHERTY
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 1:4602 N ARMENIA AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-2626
Mailing Address - Country:US
Mailing Address - Phone:813-769-1170
Mailing Address - Fax:813-200-3707
Practice Address - Street 1:4602 N ARMENIA AVE
Practice Address - Street 2:SUITE C
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603-2626
Practice Address - Country:US
Practice Address - Phone:813-769-1170
Practice Address - Fax:813-200-3707
Is Sole Proprietor?:No
Enumeration Date:2010-07-20
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-10-7041103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst