Provider Demographics
NPI:1790288371
Name:HUMPHREYS, JENNIFER E (MS, MED, BCBA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:E
Last Name:HUMPHREYS
Suffix:
Gender:F
Credentials:MS, MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 RIDGECREST RD
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511-3119
Mailing Address - Country:US
Mailing Address - Phone:408-540-4551
Mailing Address - Fax:
Practice Address - Street 1:4929 DARCY WOODS LN
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-7622
Practice Address - Country:US
Practice Address - Phone:408-540-4551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-09
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
1-18-31808103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program