Provider Demographics
NPI:1730438722
Name:JESS H. GHANNAM, PHD, INC.
Entity type:Organization
Organization Name:JESS H. GHANNAM, PHD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JESS
Authorized Official - Middle Name:H
Authorized Official - Last Name:GHANNAM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:415-921-8096
Mailing Address - Street 1:1939 DIVISADERO ST STE 3
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-2507
Mailing Address - Country:US
Mailing Address - Phone:415-921-8096
Mailing Address - Fax:415-354-3377
Practice Address - Street 1:1939 DIVISADERO ST STE 3
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-2507
Practice Address - Country:US
Practice Address - Phone:415-921-8096
Practice Address - Fax:415-354-3377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-05
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 9261103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR26383Medicare PIN
CA00PL92611Medicare UPIN