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NPI Code Detail

MEDICARE: DR. JESS H GHANNAM PHD

MEDICARE: DR. JESS H GHANNAM PHD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103G00000XClinical NeuropsychologistPSY9261CA
2103T00000XPsychologistPSY9261CA
3103TC0700XClinical PsychologistPSY9261CA
4103TF0200XForensic PsychologistPSY9261CA
5103TP2701XGroup Psychotherapy PsychologistPSY9261CA
6103TR0400XRehabilitation PsychologistPSY9261CA
72084P2900XPain Medicine (Psychiatry & Neurology) PhysicianPSY9261CA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1ZZZ20562ZOTHERCAGROUP ID NUMBER

General Provider Information

NPI Number : 1285790154
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. JESS H GHANNAM PHD
Provider Business Mailing Address
First Line : 1939 DIVISADERO ST
Second Line : # 3
City : SAN FRANCISCO
State : CA
Zip : 94115-2507
Country : US
Telephone Number : 415-921-8096
Fax Number : 415-354-3377
Provider Business Practice Location Address
First Line : 1335 STANFORD
Second Line :
City : EMERYVILLE
State : CA
Zip : 94608-2536
Country : US
Telephone Number : 510-647-5101
Fax Number : 510-647-5105
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/28/2006
Last Update Date : 09/05/2012

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