Provider Demographics
NPI:1114065380
Name:BOOTHBY, JENNIFER LYNN (PHD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:BOOTHBY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 N 36TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47803-1304
Mailing Address - Country:US
Mailing Address - Phone:812-237-3950
Mailing Address - Fax:812-237-4378
Practice Address - Street 1:INDIANA STATE UNIVERSITY PSYCHOLOGY CLINIC
Practice Address - Street 2:200 N. 7TH ST.
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47809-0001
Practice Address - Country:US
Practice Address - Phone:812-237-3317
Practice Address - Fax:812-237-8595
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041760A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical