Provider Demographics
NPI:1215693809
Name:BACIGALUPO, JENNIFER (LBA BCBA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BACIGALUPO
Suffix:
Gender:F
Credentials:LBA BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E FILLMORE ST APT 326
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-2118
Mailing Address - Country:US
Mailing Address - Phone:347-723-5366
Mailing Address - Fax:
Practice Address - Street 1:5025 E WASHINGTON ST STE 212
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85034-7439
Practice Address - Country:US
Practice Address - Phone:602-773-5773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-09
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ886516Medicaid
AZ963969Medicaid