Provider Demographics
NPI:1720546021
Name:BRENNAN, JONATHAN (BCBA)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:BRENNAN
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7360 N LINCOLN AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:LINCOLNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60712-1705
Mailing Address - Country:US
Mailing Address - Phone:855-855-2712
Mailing Address - Fax:
Practice Address - Street 1:1613 PROSPECT PARK WAY STE 110
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-9707
Practice Address - Country:US
Practice Address - Phone:970-377-9401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-05
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO11832301103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst