Provider Demographics
NPI:1528588241
Name:SOUTHERN, JENNIFER N/A (BEHAVIOR ASSISTANT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:N/A
Last Name:SOUTHERN
Suffix:
Gender:F
Credentials:BEHAVIOR ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4575 SE DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-6826
Mailing Address - Country:US
Mailing Address - Phone:561-860-7598
Mailing Address - Fax:
Practice Address - Street 1:1831 17TH CT N
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33460-6437
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-23
Last Update Date:2017-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other