Provider Demographics
NPI:1134994858
Name:MAYBERRY, JENNIFER MARIE (LMSW)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MARIE
Last Name:MAYBERRY
Suffix:
Gender:
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1103
Mailing Address - Street 2:
Mailing Address - City:RATHDRUM
Mailing Address - State:ID
Mailing Address - Zip Code:83858
Mailing Address - Country:US
Mailing Address - Phone:208-659-2049
Mailing Address - Fax:
Practice Address - Street 1:2025 W PARK PL STE 105
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2787
Practice Address - Country:US
Practice Address - Phone:208-274-3267
Practice Address - Fax:208-719-7952
Is Sole Proprietor?:No
Enumeration Date:2023-11-22
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health