Provider Demographics
NPI:1629452461
Name:WYATT, JENNIFER (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:WYATT
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 1:10569 RHAPSODY CV
Mailing Address - Street 2:
Mailing Address - City:WALLS
Mailing Address - State:MS
Mailing Address - Zip Code:38680-6001
Mailing Address - Country:US
Mailing Address - Phone:901-496-6215
Mailing Address - Fax:
Practice Address - Street 1:6858 SWINNEA RD
Practice Address - Street 2:4 RUTLAND PLACE
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9493
Practice Address - Country:US
Practice Address - Phone:662-772-5937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-10
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1-14-17227103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst