Provider Demographics
NPI:1265904072
Name:VICKHAMMER, JENNY (BCBA)
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:VICKHAMMER
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 1:1073 OVERLAND TRAIL ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:ID
Mailing Address - Zip Code:83644-5879
Mailing Address - Country:US
Mailing Address - Phone:406-250-3056
Mailing Address - Fax:
Practice Address - Street 1:12553 W EXPLORER DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-1601
Practice Address - Country:US
Practice Address - Phone:406-549-6413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-19
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-18-31807103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst