Provider Demographics
NPI:1780168013
Name:MAYBERRY, JENEI SHANAY
Entity type:Individual
Prefix:MS
First Name:JENEI
Middle Name:SHANAY
Last Name:MAYBERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 E 52ND ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98404-1386
Mailing Address - Country:US
Mailing Address - Phone:253-344-3289
Mailing Address - Fax:
Practice Address - Street 1:218 S 38TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98418-7807
Practice Address - Country:US
Practice Address - Phone:253-426-8146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-22
Last Update Date:2018-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA111524501Medicaid