Provider Demographics
NPI:1720697642
Name:MUNCY, JENNIFER RENE (BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RENE
Last Name:MUNCY
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:RENE
Other - Last Name:POOLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:321 W WALNUT ST STE 2
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6774
Mailing Address - Country:US
Mailing Address - Phone:423-202-3622
Mailing Address - Fax:423-631-0019
Practice Address - Street 1:321 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6774
Practice Address - Country:US
Practice Address - Phone:423-202-3622
Practice Address - Fax:423-631-0019
Is Sole Proprietor?:No
Enumeration Date:2020-07-27
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-20-42266103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNLBA0000000647OtherLICENSED BEHAVIOR ANALYST
VA0133001934OtherLICENSED BEHAVIOR ANALYST
TNQ060405Medicaid