Provider Demographics
NPI:1902491293
Name:HERRING, JACKIE LYNN
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:LYNN
Last Name:HERRING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 TOWNSEND ST
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-6416
Mailing Address - Country:US
Mailing Address - Phone:530-575-6909
Mailing Address - Fax:
Practice Address - Street 1:900 E MAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5853
Practice Address - Country:US
Practice Address - Phone:530-273-2244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-08
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health