Provider Demographics
NPI:1598990806
Name:WARREN, JERIDITH DIONNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JERIDITH
Middle Name:DIONNE
Last Name:WARREN
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 1:4605 FORDHAM DR
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75042-4550
Mailing Address - Country:US
Mailing Address - Phone:214-738-7017
Mailing Address - Fax:
Practice Address - Street 1:12700 HILLCREST RD
Practice Address - Street 2:SUITE 212
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2033
Practice Address - Country:US
Practice Address - Phone:214-738-7017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-17
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32218103T00000X
TX31809103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool