Provider Demographics
NPI:1134989064
Name:MAISONET, JENNIFER MARIE (RBT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:MAISONET
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51105 WACO CT APT 1
Mailing Address - Street 2:
Mailing Address - City:FORT CAVAZOS
Mailing Address - State:TX
Mailing Address - Zip Code:76544-1169
Mailing Address - Country:US
Mailing Address - Phone:254-458-4096
Mailing Address - Fax:
Practice Address - Street 1:310 W CENTRAL TEXAS EXPY STE 4
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76541-2573
Practice Address - Country:US
Practice Address - Phone:254-833-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-24-334945106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
RBT-24-334945OtherBACB