Provider Demographics
NPI:1396106795
Name:SMITH, JENA (BCBA)
Entity type:Individual
Prefix:
First Name:JENA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:JENA
Other - Middle Name:LYNN
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BCBA
Mailing Address - Street 1:1066 41ST AVE UNIT D106
Mailing Address - Street 2:
Mailing Address - City:CAPITOLA
Mailing Address - State:CA
Mailing Address - Zip Code:95010-3951
Mailing Address - Country:US
Mailing Address - Phone:480-213-5044
Mailing Address - Fax:
Practice Address - Street 1:1066 41ST AVE UNIT D106
Practice Address - Street 2:
Practice Address - City:CAPITOLA
Practice Address - State:CA
Practice Address - Zip Code:95010-3951
Practice Address - Country:US
Practice Address - Phone:480-213-5044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-11
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIBA 114103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst