Provider Demographics
NPI:1992803183
Name:LOTERY, JENNIFER LYNN (PHD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:LOTERY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:493 MAIN ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:DIAMOND SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:95619
Mailing Address - Country:US
Mailing Address - Phone:530-622-6991
Mailing Address - Fax:530-622-6991
Practice Address - Street 1:493 MAIN ST
Practice Address - Street 2:SUITE D
Practice Address - City:DIAMOND SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:95619
Practice Address - Country:US
Practice Address - Phone:530-622-6991
Practice Address - Fax:530-622-6991
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11619103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist