Provider Demographics
NPI:1063498996
Name:DAVIS, JENNIFER DUNCAN (PHD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DUNCAN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:E
Other - Last Name:DUNCAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:593 EDDY ST
Mailing Address - Street 2:APC 978
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4923
Mailing Address - Country:US
Mailing Address - Phone:401-444-4318
Mailing Address - Fax:401-444-7865
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:POB 430
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-444-4500
Practice Address - Fax:401-444-6643
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS00820103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
007010674Medicare ID - Type Unspecified