Provider Demographics
NPI:1821762147
Name:ZETLAN, JENIFER K (MA BEHAVIOIRAL SCIEN)
Entity Type:Individual
Prefix:
First Name:JENIFER
Middle Name:K
Last Name:ZETLAN
Suffix:
Gender:F
Credentials:MA BEHAVIOIRAL SCIEN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 LONGSHANK CIR
Mailing Address - Street 2:
Mailing Address - City:EAST FALMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02536-7906
Mailing Address - Country:US
Mailing Address - Phone:805-478-0269
Mailing Address - Fax:
Practice Address - Street 1:26 LONGSHANK CIR
Practice Address - Street 2:
Practice Address - City:EAST FALMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02536-7906
Practice Address - Country:US
Practice Address - Phone:805-478-0269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000X
CA168181171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171400000XOther Service ProvidersHealth & Wellness CoachGroup - Single Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASA5310668OtherBEHAVIORAL THERAPIST
CA168181OtherYOGA ALLIANCE