Provider Demographics
NPI:1245714021
Name:SIPE, JENNIFER (RBT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SIPE
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11172 ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-9163
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11172 ADAMS ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-9163
Practice Address - Country:US
Practice Address - Phone:616-726-1909
Practice Address - Fax:616-301-2211
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIW-325-398-564-151OtherDRIVER'S LICENSE