Provider Demographics
NPI:1629337944
Name:BANTA, JENNIFER A (PHD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:A
Last Name:BANTA
Suffix:
Gender:F
Credentials:PHD
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Other - Credentials:
Mailing Address - Street 1:815 BUENA VISTA AVE W
Mailing Address - Street 2:WALDEN HOUSE-HAFC DUAL RECOVERY PROGRAM
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94117-4108
Mailing Address - Country:US
Mailing Address - Phone:415-558-4206
Mailing Address - Fax:415-558-4235
Practice Address - Street 1:815 BUENA VISTA AVE W
Practice Address - Street 2:WALDEN HOUSE-HAFC DUAL RECOVERY PROGRAM
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94117-4108
Practice Address - Country:US
Practice Address - Phone:415-558-4206
Practice Address - Fax:415-558-4235
Is Sole Proprietor?:No
Enumeration Date:2012-05-07
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPSY20473103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist