Provider Demographics
NPI:1831122100
Name:DANNENMAIER, JESSICA (PSY,D)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:DANNENMAIER
Suffix:
Gender:F
Credentials:PSY,D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6072 BRYNWOOD DR
Mailing Address - Street 2:105
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-5829
Mailing Address - Country:US
Mailing Address - Phone:815-979-3211
Mailing Address - Fax:815-398-2116
Practice Address - Street 1:6072 BRYNWOOD DR
Practice Address - Street 2:105
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-5829
Practice Address - Country:US
Practice Address - Phone:815-979-3211
Practice Address - Fax:815-398-2116
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213750Medicare ID - Type Unspecified