Provider Demographics
NPI:1659941086
Name:DODGE, JENNIFER SUE (BACB499833)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SUE
Last Name:DODGE
Suffix:
Gender:F
Credentials:BACB499833
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 154
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:WA
Mailing Address - Zip Code:98812-0154
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:42 LOST RIVER RD
Practice Address - Street 2:
Practice Address - City:MAZAMA
Practice Address - State:WA
Practice Address - Zip Code:98833-9707
Practice Address - Country:US
Practice Address - Phone:404-247-4514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WABACB499833103K00000X
WARBT-21-178990106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst