Provider Demographics
NPI:1124724539
Name:BERRY, JONNY (LPC)
Entity type:Individual
Prefix:MR
First Name:JONNY
Middle Name:
Last Name:BERRY
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:971 LAKELAND DR STE 1159
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4609
Mailing Address - Country:US
Mailing Address - Phone:601-982-1010
Mailing Address - Fax:601-366-0436
Practice Address - Street 1:971 LAKELAND DR STE 654
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4605
Practice Address - Country:US
Practice Address - Phone:601-982-1010
Practice Address - Fax:601-366-0436
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-07
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2907101Y00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor