Provider Demographics
NPI:1932814647
Name:JOHANSSON, JENNIFER ELISE (BCBA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELISE
Last Name:JOHANSSON
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 1:113 SALEM ST APT 1
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02113-2254
Mailing Address - Country:US
Mailing Address - Phone:973-768-0584
Mailing Address - Fax:
Practice Address - Street 1:113 SALEM ST APT 1
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02113-2254
Practice Address - Country:US
Practice Address - Phone:973-768-0584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-17
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3968-MH-B1103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst