Provider Demographics
NPI:1033577804
Name:BERRY, JEANETTE LATISE
Entity Type:Individual
Prefix:MS
First Name:JEANETTE
Middle Name:LATISE
Last Name:BERRY
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 1:12207 DAVENTRY CIR
Mailing Address - Street 2:
Mailing Address - City:GREER
Mailing Address - State:SC
Mailing Address - Zip Code:29650-2256
Mailing Address - Country:US
Mailing Address - Phone:864-361-5513
Mailing Address - Fax:
Practice Address - Street 1:12207 DAVENTRY CIR
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-2256
Practice Address - Country:US
Practice Address - Phone:864-361-5513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-08
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC301100Medicaid
SC301100Medicaid