Provider Demographics
NPI:1699483453
Name:WEAVER, JENNA
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:WEAVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 ALUM CREEK DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43209-2705
Mailing Address - Country:US
Mailing Address - Phone:615-262-7520
Mailing Address - Fax:614-352-2334
Practice Address - Street 1:1350 ALUM CREEK DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43209-2705
Practice Address - Country:US
Practice Address - Phone:614-262-7520
Practice Address - Fax:614-352-2334
Is Sole Proprietor?:No
Enumeration Date:2022-11-10
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-21-168449106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician