Provider Demographics
NPI:1003158296
Name:PENROD, JANA LEE (PSYCHOLOGIST)
Entity Type:Individual
Prefix:
First Name:JANA
Middle Name:LEE
Last Name:PENROD
Suffix:
Gender:F
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-2131
Mailing Address - Country:US
Mailing Address - Phone:517-264-1313
Mailing Address - Fax:517-266-0553
Practice Address - Street 1:623 N BROAD ST
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-2131
Practice Address - Country:US
Practice Address - Phone:517-264-1313
Practice Address - Fax:517-266-0553
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-26
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL2053661103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst