Provider Demographics
NPI:1770079873
Name:BRUEN, JENNIFER (BCBA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BRUEN
Suffix:
Gender:
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8029 KINGSWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-2144
Mailing Address - Country:US
Mailing Address - Phone:321-298-5055
Mailing Address - Fax:
Practice Address - Street 1:166 PROFESSIONAL WAY
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-6391
Practice Address - Country:US
Practice Address - Phone:561-570-1566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-02
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-17-28598103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1770079873Medicaid