Provider Demographics
NPI:1598356180
Name:OMELIANOFF, JENNIFER NATASHA (BCBA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NATASHA
Last Name:OMELIANOFF
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 1:2335 PEAK RD
Mailing Address - Street 2:
Mailing Address - City:LYNDONVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05851-9546
Mailing Address - Country:US
Mailing Address - Phone:203-233-5497
Mailing Address - Fax:
Practice Address - Street 1:2335 PEAK RD
Practice Address - Street 2:
Practice Address - City:LYNDONVILLE
Practice Address - State:VT
Practice Address - Zip Code:05851-9546
Practice Address - Country:US
Practice Address - Phone:203-233-5497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0-21-11688106E00000X
TX1-23-66739103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst