Provider Demographics
NPI:1790073880
Name:GANNON, J PATRICK (PHD)
Entity Type:Individual
Prefix:DR
First Name:J
Middle Name:PATRICK
Last Name:GANNON
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 1:417 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94118-1711
Mailing Address - Country:US
Mailing Address - Phone:415-751-8927
Mailing Address - Fax:
Practice Address - Street 1:417 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94118-1711
Practice Address - Country:US
Practice Address - Phone:415-751-8927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-11
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY7201103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical