Basic Information
| Provider Information | |||||||||
| NPI: | 1316372139 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENRETIG | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | MARY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3003 N CENTRAL AVE STE 1600 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023233492 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1840 E BROADWAY RD | ||||||||
| Address2: | |||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852821614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0224372776 | ||||||||
| FaxNumber: | 4809271092 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2013 | ||||||||
| LastUpdateDate: | 08/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103TC0700X | PSY-005432 | AZ | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.