Provider Demographics
NPI:1306197256
Name:HENDERSON, JESSICA BERRY (PHD, LPC)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:BERRY
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:PHD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2351 S RIDGE POINT WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-8522
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3852 N EAGLE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-0750
Practice Address - Country:US
Practice Address - Phone:208-378-0014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-01
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID4508101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional