Provider Demographics
NPI:1730641853
Name:O'CONNELL, JENNIFER (BA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:O'CONNELL
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 POTRERO GRANDE DR STE 7
Mailing Address - Street 2:
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770-4167
Mailing Address - Country:US
Mailing Address - Phone:626-872-8068
Mailing Address - Fax:626-508-1186
Practice Address - Street 1:1600 POTRERO GRANDE DR STE 7
Practice Address - Street 2:
Practice Address - City:ROSEMEAD
Practice Address - State:CA
Practice Address - Zip Code:91770-4167
Practice Address - Country:US
Practice Address - Phone:626-872-8068
Practice Address - Fax:626-508-1186
Is Sole Proprietor?:No
Enumeration Date:2019-04-05
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X
CA12147184103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other