Provider Demographics
NPI:1316346612
Name:WAZ, JENNA (MA, BCBA)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:WAZ
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8200 WOODGLEN LN
Mailing Address - Street 2:#201
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60516-4551
Mailing Address - Country:US
Mailing Address - Phone:602-471-6802
Mailing Address - Fax:630-395-9198
Practice Address - Street 1:21 ORCHARD LN
Practice Address - Street 2:
Practice Address - City:MIDDLEFIELD
Practice Address - State:CT
Practice Address - Zip Code:06455-1151
Practice Address - Country:US
Practice Address - Phone:860-250-5849
Practice Address - Fax:860-349-2280
Is Sole Proprietor?:No
Enumeration Date:2014-08-22
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-10-7692103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst