Provider Demographics
NPI:1467462390
Name:HENRY, JEANNE M (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEANNE
Middle Name:M
Last Name:HENRY
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 1:2220 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-2104
Mailing Address - Country:US
Mailing Address - Phone:619-230-1780
Mailing Address - Fax:619-230-1066
Practice Address - Street 1:2220 5TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2104
Practice Address - Country:US
Practice Address - Phone:619-230-1780
Practice Address - Fax:619-230-1066
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15292103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY152920Medicaid
CACP15292Medicare ID - Type Unspecified