Provider Demographics
NPI:1972172336
Name:RUSSO, JENNIFER (BCBA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 N REGENT ST
Mailing Address - Street 2:
Mailing Address - City:PORT CHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:10573-2642
Mailing Address - Country:US
Mailing Address - Phone:617-233-9907
Mailing Address - Fax:
Practice Address - Street 1:243 N REGENT ST
Practice Address - Street 2:
Practice Address - City:PORT CHESTER
Practice Address - State:NY
Practice Address - Zip Code:10573-2642
Practice Address - Country:US
Practice Address - Phone:617-233-9907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-21
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1200103K00000X
NY002110103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst