Provider Demographics
NPI:1407027469
Name:JENIFER, ERICKA S (PHD)
Entity Type:Individual
Prefix:
First Name:ERICKA
Middle Name:S
Last Name:JENIFER
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 1:1780 DOOLITTLE AVE
Mailing Address - Street 2:301ST MDS, MENTAL HEALTH SECTION
Mailing Address - City:NAS/JRB
Mailing Address - State:TX
Mailing Address - Zip Code:76127-1134
Mailing Address - Country:US
Mailing Address - Phone:817-782-7785
Mailing Address - Fax:817-782-6522
Practice Address - Street 1:1780 DOOLITTLE AVE
Practice Address - Street 2:301ST MDS, MENTAL HEALTH SECTION
Practice Address - City:NAS/JRB
Practice Address - State:TX
Practice Address - Zip Code:76127-1134
Practice Address - Country:US
Practice Address - Phone:817-782-7785
Practice Address - Fax:817-782-6522
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-18
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008482103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical