Provider Demographics
NPI:1689106585
Name:DOUGLASS, JENNA MICHELLE (BCBA)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:MICHELLE
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:MICHELLE
Other - Last Name:GILREATH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:7603 CARRINGTON FOREST LN
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-3212
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7603 CARRINGTON FOREST LN
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-3212
Practice Address - Country:US
Practice Address - Phone:704-560-5405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-30
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-18-33534103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst