Provider Demographics
NPI:1104178078
Name:PENNER, JEFFREY (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:
Last Name:PENNER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8885 RIO SAN DIEGO DR
Mailing Address - Street 2:SUITE 325
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-1624
Mailing Address - Country:US
Mailing Address - Phone:619-297-8640
Mailing Address - Fax:619-297-0122
Practice Address - Street 1:8885 RIO SAN DIEGO DR
Practice Address - Street 2:SUITE 325
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-1624
Practice Address - Country:US
Practice Address - Phone:619-297-8640
Practice Address - Fax:619-297-0122
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-02
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7094103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical