Provider Demographics
NPI:1740624758
Name:JANNETTE, MYRRIAH (PHD)
Entity type:Individual
Prefix:
First Name:MYRRIAH
Middle Name:
Last Name:JANNETTE
Suffix:
Gender:
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5536 ENCHANTED AVE
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-3242
Mailing Address - Country:US
Mailing Address - Phone:717-236-2121
Mailing Address - Fax:
Practice Address - Street 1:5 CHANTILLY CT
Practice Address - Street 2:
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17050-8220
Practice Address - Country:US
Practice Address - Phone:717-236-2121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-20
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X, 374J00000X
MDU02222171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No374J00000XNursing Service Related ProvidersDoula