Provider Demographics
NPI:1811002819
Name:JENNY, SUSAN MARIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MARIE
Last Name:JENNY
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 1:954 RISA RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-3418
Mailing Address - Country:US
Mailing Address - Phone:925-284-0685
Mailing Address - Fax:
Practice Address - Street 1:954 RISA RD
Practice Address - Street 2:SUITE A
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-3418
Practice Address - Country:US
Practice Address - Phone:925-284-0685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 4303103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PL43030Medicare ID - Type UnspecifiedMEDICARE