Provider Demographics
NPI:1811910490
Name:MERRILL, JENNIFER ANN (MA, MFT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:MERRILL
Suffix:
Gender:F
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4523
Mailing Address - Street 2:
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95518-4523
Mailing Address - Country:US
Mailing Address - Phone:707-825-8123
Mailing Address - Fax:707-825-8123
Practice Address - Street 1:455 I ST STE 207
Practice Address - Street 2:
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521
Practice Address - Country:US
Practice Address - Phone:707-825-8123
Practice Address - Fax:707-825-8123
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38586106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist