Provider Demographics
NPI:1821892704
Name:MADDEN, JENNIE GRACE (BCBA)
Entity type:Individual
Prefix:
First Name:JENNIE
Middle Name:GRACE
Last Name:MADDEN
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 1:3464 LEWIS LOOP RD SE
Mailing Address - Street 2:
Mailing Address - City:BOLIVIA
Mailing Address - State:NC
Mailing Address - Zip Code:28422-7560
Mailing Address - Country:US
Mailing Address - Phone:910-789-0258
Mailing Address - Fax:
Practice Address - Street 1:101 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7000
Practice Address - Country:US
Practice Address - Phone:919-375-0475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-01
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1-25-80377103K00000X
NCRBT-23-261018106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst