Provider Demographics
NPI:1548766454
Name:MIRI, JENIFER
Entity Type:Individual
Prefix:
First Name:JENIFER
Middle Name:
Last Name:MIRI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6081 MERIDIAN AVE STE 70-298
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95120-2752
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6370 MOJAVE DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95120-5310
Practice Address - Country:US
Practice Address - Phone:408-247-4123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-01
Last Update Date:2018-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19827103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist