Provider Demographics
NPI:1316544471
Name:BERRY, JERMAINE
Entity Type:Individual
Prefix:
First Name:JERMAINE
Middle Name:
Last Name:BERRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2314 KENWORTHY DR
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-2104
Mailing Address - Country:US
Mailing Address - Phone:503-819-0839
Mailing Address - Fax:
Practice Address - Street 1:2314 KENWORTHY DR
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-2104
Practice Address - Country:US
Practice Address - Phone:832-997-8854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX01262018OtherCOUNCELOR
TX09072018Medicaid