Provider Demographics
NPI:1124194154
Name:PANISH, JACQUELINE B (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:B
Last Name:PANISH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2560 MONTESSOURI ST
Mailing Address - Street 2:SUITE #112
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-3061
Mailing Address - Country:US
Mailing Address - Phone:702-396-9000
Mailing Address - Fax:702-368-3009
Practice Address - Street 1:2560 MONTESSOURI ST
Practice Address - Street 2:SUITE #112
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-3061
Practice Address - Country:US
Practice Address - Phone:702-396-9000
Practice Address - Fax:702-368-3009
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPY0461103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical