Provider Demographics
NPI:1184704066
Name:PANNING, JENNIFER C (PSYD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:C
Last Name:PANNING
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 CHURCH ST STE 520
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-4581
Mailing Address - Country:US
Mailing Address - Phone:847-864-0600
Mailing Address - Fax:
Practice Address - Street 1:636 CHURCH ST STE 520
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4581
Practice Address - Country:US
Practice Address - Phone:847-864-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL71006778103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1634738OtherBLUE CROSS/BLUE SHIELD