Provider Demographics
NPI:1952698011
Name:VANDERBURG, JENNIFER D (BCABA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:D
Last Name:VANDERBURG
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1808 ROSE ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-4219
Mailing Address - Country:US
Mailing Address - Phone:940-723-4488
Mailing Address - Fax:940-723-4490
Practice Address - Street 1:1800 ROSE ST
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-4219
Practice Address - Country:US
Practice Address - Phone:940-322-2372
Practice Address - Fax:940-322-3578
Is Sole Proprietor?:No
Enumeration Date:2011-07-08
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0114127103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst