Provider Demographics
NPI:1588110456
Name:JENNIFER RENEE CAZALES
Entity type:Organization
Organization Name:JENNIFER RENEE CAZALES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:CAZALES
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:203-606-1676
Mailing Address - Street 1:2201 MOSSY OAKS RD
Mailing Address - Street 2:A3
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-7600
Mailing Address - Country:US
Mailing Address - Phone:203-606-1676
Mailing Address - Fax:
Practice Address - Street 1:2201 MOSSY OAKS RD
Practice Address - Street 2:A3
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-7600
Practice Address - Country:US
Practice Address - Phone:203-606-1676
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-30
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-15-18387103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty