Provider Demographics
NPI:1184378440
Name:SQUILLO, JENNA R (BCBA)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:R
Last Name:SQUILLO
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 1:18 N CATHERINE AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-5930
Mailing Address - Country:US
Mailing Address - Phone:708-482-8453
Mailing Address - Fax:
Practice Address - Street 1:18 N CATHERINE AVE
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-5930
Practice Address - Country:US
Practice Address - Phone:708-482-8453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-21-53798103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty