Provider Demographics
NPI:1770932014
Name:MOODY, JENILEE (BCBA)
Entity type:Individual
Prefix:
First Name:JENILEE
Middle Name:
Last Name:MOODY
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1316 W DRAGOON TRL
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-4713
Mailing Address - Country:US
Mailing Address - Phone:707-951-1104
Mailing Address - Fax:
Practice Address - Street 1:2146 CHARLES DR
Practice Address - Street 2:
Practice Address - City:STEVENSVILLE
Practice Address - State:MI
Practice Address - Zip Code:49127-9523
Practice Address - Country:US
Practice Address - Phone:707-951-1104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-20-45952103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst