Healthcare Provider Details

I. General information

NPI: 1386994754
Provider Name (Legal Business Name): JENNIFER SUZANNE TARI PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2012
Last Update Date: 09/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 BRANSCOMB RD.
LAYTONVILLE CA
95454
US

IV. Provider business mailing address

PO BOX 1116
UPPER LAKE CA
95485
US

V. Phone/Fax

Practice location:
  • Phone: 707-984-6131
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY23230
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: