Provider Demographics
NPI:1669697611
Name:GOODIS-BERRY, JENNIFER LYNNE (MS)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNNE
Last Name:GOODIS-BERRY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNNE
Other - Last Name:GOODIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:344 PLACERVILLE DR
Mailing Address - Street 2:STE 17
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-3920
Mailing Address - Country:US
Mailing Address - Phone:530-621-6333
Mailing Address - Fax:
Practice Address - Street 1:344 PLACERVILLE DR.
Practice Address - Street 2:STE 17
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667
Practice Address - Country:US
Practice Address - Phone:530-621-6333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 52840106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist