Provider Demographics
NPI:1508072216
Name:FANNING, JOHN TRUMAN (PHD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:TRUMAN
Last Name:FANNING
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 1:715 PECAN GROVE LN
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:LA
Mailing Address - Zip Code:70121-1130
Mailing Address - Country:US
Mailing Address - Phone:504-421-0730
Mailing Address - Fax:888-959-6762
Practice Address - Street 1:4440 CANAL STREET
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-6021
Practice Address - Country:US
Practice Address - Phone:504-421-0730
Practice Address - Fax:888-959-6762
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA468103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1552836Medicaid
LA56198Medicare PIN
LA247706YJKQMedicare PIN
LA1552836Medicaid