Provider Demographics
NPI:1356171151
Name:LENNON, JODI (BCABA)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:LENNON
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 VILLA GRANDE ST UNIT E
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-9267
Mailing Address - Country:US
Mailing Address - Phone:631-335-2090
Mailing Address - Fax:
Practice Address - Street 1:2952 LITTLE BETHEL RD
Practice Address - Street 2:
Practice Address - City:GREEN SEA
Practice Address - State:SC
Practice Address - Zip Code:29545-3729
Practice Address - Country:US
Practice Address - Phone:843-733-2184
Practice Address - Fax:843-894-3610
Is Sole Proprietor?:No
Enumeration Date:2024-08-06
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0-24-15434103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst