Provider Demographics
NPI:1659656429
Name:AVERBECK, JENNA K
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:K
Last Name:AVERBECK
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 1:901 CALEDONIA ST
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54603-2616
Mailing Address - Country:US
Mailing Address - Phone:608-785-4100
Mailing Address - Fax:608-785-4101
Practice Address - Street 1:901 CALEDONIA ST
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54603-2616
Practice Address - Country:US
Practice Address - Phone:608-785-4100
Practice Address - Fax:608-785-4101
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-12
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33-140103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-10-7467OtherBEHAVIOR ANALYST CERTIFICATION BOARD, INC