Provider Demographics
NPI:1477763738
Name:KERRY, JEAN M (PHD)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:M
Last Name:KERRY
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 1:1 W SAMPLE RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33064-3547
Mailing Address - Country:US
Mailing Address - Phone:954-786-2255
Mailing Address - Fax:
Practice Address - Street 1:1 W SAMPLE RD
Practice Address - Street 2:SUITE 205
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33064-3547
Practice Address - Country:US
Practice Address - Phone:954-786-2255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0005577103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54149Medicare ID - Type Unspecified