Provider Demographics
NPI:1053775411
Name:FITZPATRICK, JENNIFER P (BCBA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:P
Last Name:FITZPATRICK
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 1:1030 CRYSTAL BAY CT
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-7275
Mailing Address - Country:US
Mailing Address - Phone:805-668-8961
Mailing Address - Fax:
Practice Address - Street 1:1030 CRYSTAL BAY CT
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-7275
Practice Address - Country:US
Practice Address - Phone:805-668-8961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-11
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-16-21925103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst