Provider Demographics
NPI:1750070488
Name:KHOURY, JENNI (MA)
Entity type:Individual
Prefix:
First Name:JENNI
Middle Name:
Last Name:KHOURY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:442 VISTA ROMA
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-3553
Mailing Address - Country:US
Mailing Address - Phone:949-310-6070
Mailing Address - Fax:
Practice Address - Street 1:442 VISTA ROMA
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-3553
Practice Address - Country:US
Practice Address - Phone:949-310-6070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-08
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA210109516103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool