Provider Demographics
NPI:1417662313
Name:DOHERTY, JENNA MARIE (LMHC-D)
Entity type:Individual
Prefix:MRS
First Name:JENNA
Middle Name:MARIE
Last Name:DOHERTY
Suffix:
Gender:
Credentials:LMHC-D
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:M
Other - Last Name:CAMPISI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MHC-P
Mailing Address - Street 1:547 WEST RD
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:NY
Mailing Address - Zip Code:14580-1130
Mailing Address - Country:US
Mailing Address - Phone:585-643-8080
Mailing Address - Fax:
Practice Address - Street 1:547 WEST RD
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:NY
Practice Address - Zip Code:14580-1130
Practice Address - Country:US
Practice Address - Phone:585-643-8080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-16
Last Update Date:2025-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013496101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY18-P107652-01OtherLICENSE NUMBER