Provider Demographics
NPI:1578130522
Name:BAINE, JENNA (LBA, BCBA, RBT)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:BAINE
Suffix:
Gender:F
Credentials:LBA, BCBA, RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6413 QUINCE RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-8219
Mailing Address - Country:US
Mailing Address - Phone:901-690-5213
Mailing Address - Fax:901-666-8440
Practice Address - Street 1:6413 QUINCE RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-8219
Practice Address - Country:US
Practice Address - Phone:901-690-5213
Practice Address - Fax:901-666-8440
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
TNRBT-21-171312106S00000X
TN928103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNRBT-21-171312OtherBACB
TN928OtherDEPARTMENT OF HEALTH LICENSURE TN