Provider Demographics
NPI:1447717541
Name:SPROUSE, JENNIFER LEE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:SPROUSE
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 1:1819 FLESHER AVE
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45420-2916
Mailing Address - Country:US
Mailing Address - Phone:937-902-4065
Mailing Address - Fax:
Practice Address - Street 1:919 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-3804
Practice Address - Country:US
Practice Address - Phone:937-878-4614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRBT-18-69978106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician