Provider Demographics
NPI:1679743942
Name:MAKUCH, JENNIFER (BCBA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MAKUCH
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 1:52 CLOVER SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:WILLINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06279-1846
Mailing Address - Country:US
Mailing Address - Phone:508-831-8753
Mailing Address - Fax:
Practice Address - Street 1:23 WARE ST
Practice Address - Street 2:
Practice Address - City:WEST BROOKFIELD
Practice Address - State:MA
Practice Address - Zip Code:01585-3137
Practice Address - Country:US
Practice Address - Phone:508-963-2213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-03
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1102103K00000X
MA1-05-2253103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst