MEDICARE: DR. JEANNE M HENRY PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY15292	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1467462390
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEANNE M HENRY PH.D.

Provider Business Mailing Address
First Line	:	2220 5TH AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92101-2104
Country	:	US
Telephone Number	:	619-230-1780
Fax Number	:	619-230-1066

Provider Business Practice Location Address
First Line	:	2220 5TH AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92101-2104
Country	:	US
Telephone Number	:	619-230-1780
Fax Number	:	619-230-1066

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2006
Last Update Date	:	07/08/2007

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