Provider Demographics
NPI:1679304950
Name:WHITEHALL, JENNIFER MAE (BCBA)
Entity type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:MAE
Last Name:WHITEHALL
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 1:3211 W CORTLAND ST APT 12
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-0141
Mailing Address - Country:US
Mailing Address - Phone:617-756-6964
Mailing Address - Fax:
Practice Address - Street 1:3109 W NORTH SHORE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645-4002
Practice Address - Country:US
Practice Address - Phone:847-676-5398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-09
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-24-71621103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst