Provider Demographics
NPI:1194947259
Name:BYRNE, JENNIE (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:JENNIE
Middle Name:
Last Name:BYRNE
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:DR
Other - First Name:JENNIE
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD, PHD
Mailing Address - Street 1:5009 MILL HILL LN
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27517-7443
Mailing Address - Country:US
Mailing Address - Phone:919-428-5154
Mailing Address - Fax:
Practice Address - Street 1:12900 PARK PLAZA DR STE 150
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-9329
Practice Address - Country:US
Practice Address - Phone:562-977-4674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC145081261QM0850X, 103TP0016X
TN596542084P0800X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
No103T00000XBehavioral Health & Social Service ProvidersPsychologist