Provider Demographics
NPI:1790798247
Name:HANNON, JUNE ROSEANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:JUNE
Middle Name:ROSEANN
Last Name:HANNON
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 1:2111 LIDO CIR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-6014
Mailing Address - Country:US
Mailing Address - Phone:209-565-1365
Mailing Address - Fax:209-474-7421
Practice Address - Street 1:2111 LIDO CIR
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6014
Practice Address - Country:US
Practice Address - Phone:209-565-1365
Practice Address - Fax:209-474-7421
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY5871103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPL58711Medicare UPIN