Provider Demographics
NPI:1053992644
Name:PERRY, JENNIFER ROSE (BS, RBT, QMHP-T)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:ROSE
Last Name:PERRY
Suffix:
Gender:F
Credentials:BS, RBT, QMHP-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:583 BEECHWOOD DR APT 7
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-5762
Mailing Address - Country:US
Mailing Address - Phone:413-887-8363
Mailing Address - Fax:
Practice Address - Street 1:20566 TIMBERLAKE RD STE A
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-7221
Practice Address - Country:US
Practice Address - Phone:434-239-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-15
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-21-163925106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician