Provider Demographics
NPI:1043021561
Name:PANGAN, JERICAH
Entity type:Individual
Prefix:
First Name:JERICAH
Middle Name:
Last Name:PANGAN
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 1:5963A KENTSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45440-4253
Mailing Address - Country:US
Mailing Address - Phone:937-952-6379
Mailing Address - Fax:
Practice Address - Street 1:5963A KENTSHIRE DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45440-4253
Practice Address - Country:US
Practice Address - Phone:937-952-6379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-15
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician