Provider Demographics
NPI:1891387965
Name:BETHKE, JENNIFER JOY (LBS RBT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JOY
Last Name:BETHKE
Suffix:
Gender:F
Credentials:LBS RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 WHITE HORSE PIKE
Mailing Address - Street 2:
Mailing Address - City:HADDON HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:08035-1706
Mailing Address - Country:US
Mailing Address - Phone:856-616-9442
Mailing Address - Fax:
Practice Address - Street 1:2200 SAINT JAMES PL
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-5860
Practice Address - Country:US
Practice Address - Phone:856-616-9442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-09
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH005208103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
PABH005208OtherCOMMONWEALTH OF PENNSYLVANIA