Provider Demographics
NPI:1255940011
Name:BERRY, JENNIFER M (LCSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:BERRY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:CARL JUNCTION
Mailing Address - State:MO
Mailing Address - Zip Code:64834-9558
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:931 E 32ND ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-2878
Practice Address - Country:US
Practice Address - Phone:417-347-4374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20190115411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical