Provider Demographics
NPI:1588225494
Name:PRUS, JENNIFER NICOLE (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:NICOLE
Last Name:PRUS
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 1:1507 GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-1632
Mailing Address - Country:US
Mailing Address - Phone:906-204-9590
Mailing Address - Fax:
Practice Address - Street 1:1507 GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-1632
Practice Address - Country:US
Practice Address - Phone:906-204-9590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-23
Last Update Date:2019-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst