Healthcare Provider Details

I. General information

NPI: 1134470271
Provider Name (Legal Business Name): JERI GENTRY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2012
Last Update Date: 03/17/2022
Certification Date: 03/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 N 140TH AVE
GOODYEAR AZ
85395-2437
US

IV. Provider business mailing address

2620 N 140TH AVE STE 101
GOODYEAR AZ
85395-2437
US

V. Phone/Fax

Practice location:
  • Phone: 623-536-7956
  • Fax:
Mailing address:
  • Phone: 623-536-7956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY-005288
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPSY-005288
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License NumberPSY-005288
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY-005288
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: