Provider Demographics
NPI:1336907872
Name:MANZO, JENNIFER LYNN (BCBA, LBA)
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:LYNN
Last Name:MANZO
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 1:7809 SARDIS RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28270-2757
Mailing Address - Country:US
Mailing Address - Phone:908-313-5819
Mailing Address - Fax:
Practice Address - Street 1:111 CLEBOURNE ST STE 200
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-1760
Practice Address - Country:US
Practice Address - Phone:704-363-3777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133002390103K00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst