Provider Demographics
NPI:1548509649
Name:QUEEN, JENNIFER EILEEN (MED BCBA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:EILEEN
Last Name:QUEEN
Suffix:
Gender:F
Credentials:MED BCBA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:EILEEN
Other - Last Name:MCCALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED, BCBA
Mailing Address - Street 1:8017 N SUNDANCE DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-7028
Mailing Address - Country:US
Mailing Address - Phone:208-659-5517
Mailing Address - Fax:
Practice Address - Street 1:8017 N SUNDANCE DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-7028
Practice Address - Country:US
Practice Address - Phone:208-659-5517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-08
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-11-9676103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst