Provider Demographics
NPI:1770943284
Name:BETTALE, JENNIFER (BCBA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BETTALE
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 1:7203 DARTMOUTH AVE
Mailing Address - Street 2:2E
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63130-3007
Mailing Address - Country:US
Mailing Address - Phone:773-272-5598
Mailing Address - Fax:
Practice Address - Street 1:105 SHERIFF DIERKER CT
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-2468
Practice Address - Country:US
Practice Address - Phone:636-978-7785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-25
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1-15-19852103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst