Provider Demographics
NPI:1205233822
Name:GONZALEZ, JENNA (BCBA, LBA)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7027 OLD MADISON PIKE NW STE 108
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35806-2369
Mailing Address - Country:US
Mailing Address - Phone:618-943-3754
Mailing Address - Fax:618-943-3657
Practice Address - Street 1:11020 STATE ROUTE 250
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62439-3379
Practice Address - Country:US
Practice Address - Phone:618-943-3754
Practice Address - Fax:618-943-3657
Is Sole Proprietor?:No
Enumeration Date:2014-11-25
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
AL2018-074103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036072942Medicaid
ILC48402Medicare UPIN
IL036072942Medicaid