Provider Demographics
NPI:1205573722
Name:VANTA, JENNIFER (BCBA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:VANTA
Suffix:
Gender:
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 INTERNATIONAL PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5028
Mailing Address - Country:US
Mailing Address - Phone:407-915-7729
Mailing Address - Fax:407-588-6294
Practice Address - Street 1:4106 COLUMBIA RD STE 101
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-1482
Practice Address - Country:US
Practice Address - Phone:706-425-0583
Practice Address - Fax:762-224-3463
Is Sole Proprietor?:No
Enumeration Date:2022-05-16
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
GA1-25-79946103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician