Provider Demographics
NPI:1548086671
Name:GANZ, JENNIFER LISA
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LISA
Last Name:GANZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3420 HICKORY AVE APT B
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21211-2421
Mailing Address - Country:US
Mailing Address - Phone:443-799-4486
Mailing Address - Fax:
Practice Address - Street 1:1300 W 36TH ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211-2303
Practice Address - Country:US
Practice Address - Phone:443-799-4486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-22
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool