Provider Demographics
NPI:1447809645
Name:DE SOUZA ANDRADE, JENNIFER I (RBT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:I
Last Name:DE SOUZA ANDRADE
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 1:4871 WISTERIA LN
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-6996
Mailing Address - Country:US
Mailing Address - Phone:520-236-2687
Mailing Address - Fax:
Practice Address - Street 1:1110 13TH ST STE D
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-2246
Practice Address - Country:US
Practice Address - Phone:706-780-1704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician