Provider Demographics
NPI:1447723911
Name:PANISH, JENNIFER RACHEL (PSYD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RACHEL
Last Name:PANISH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3867 HOWE ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-5343
Mailing Address - Country:US
Mailing Address - Phone:510-595-5509
Mailing Address - Fax:
Practice Address - Street 1:3867 HOWE ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5343
Practice Address - Country:US
Practice Address - Phone:510-595-5509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25281103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist