Provider Demographics
NPI:1992268098
Name:FORREST, JENNA MARIE (MA, BCBA, LBA)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:MARIE
Last Name:FORREST
Suffix:
Gender:F
Credentials:MA, BCBA, LBA
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:MARIE
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:2904 FOLTZ DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-2525
Practice Address - Country:US
Practice Address - Phone:859-795-3000
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-21-53278103K00000X
RBT-18-60331106S00000X
KY273594103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
RBT-18-60331OtherRBT CERTIFICATE
1-21-53278OtherBCBA CERTIFICATE