Provider Demographics
NPI:1558502906
Name:WAPNER, JEFFREY GALLANT (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:GALLANT
Last Name:WAPNER
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 1:7213 BATEMAN ST
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60516-3793
Mailing Address - Country:US
Mailing Address - Phone:914-329-4185
Mailing Address - Fax:
Practice Address - Street 1:50 75TH ST
Practice Address - Street 2:SUITE 212
Practice Address - City:WILLOWBROOK
Practice Address - State:IL
Practice Address - Zip Code:60527-2393
Practice Address - Country:US
Practice Address - Phone:914-329-4185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-16
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008511-1103TC0700X
IL071.008571103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical