Provider Demographics
NPI:1366737066
Name:REILLY, JENNIFER MARIE (BCBA)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:MARIE
Last Name:REILLY
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 OAKHILL DR
Mailing Address - Street 2:
Mailing Address - City:SANDIA PARK
Mailing Address - State:NM
Mailing Address - Zip Code:87047-9332
Mailing Address - Country:US
Mailing Address - Phone:970-623-6369
Mailing Address - Fax:
Practice Address - Street 1:500 MARQUETTE AVE NW STE 1200
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-5312
Practice Address - Country:US
Practice Address - Phone:970-623-6369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-10
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-11-9563103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst