Provider Demographics
NPI:1134778517
Name:MCCULLOCH-KONKEL, JENNIFER SARAH (BCBA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SARAH
Last Name:MCCULLOCH-KONKEL
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 1:7360 N LINCOLN AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:LINCOLNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60712-1705
Mailing Address - Country:US
Mailing Address - Phone:970-690-0595
Mailing Address - Fax:
Practice Address - Street 1:55349 COUNTY ROAD 15
Practice Address - Street 2:
Practice Address - City:CARR
Practice Address - State:CO
Practice Address - Zip Code:80612-8904
Practice Address - Country:US
Practice Address - Phone:970-690-0595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-09
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-18-31150103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst