Provider Demographics
NPI:1265958953
Name:DEROCHER, JENNIFER (BCBA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DEROCHER
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LEE
Other - Last Name:MANUAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10191 HODGE RD
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:IN
Mailing Address - Zip Code:46118-9167
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:374 MERIDIAN PARKE LN
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-9406
Practice Address - Country:US
Practice Address - Phone:317-849-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-15
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-17-26799103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst