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636 Church St. Ste. 510 Evanston IL 60201-4508 | |
| (847) 864-0600 | |
| (847) 859-6996 |
| Full Name | |
|---|---|
| Speciality | Psychologist - Clinical |
| Location | 636 Church St., Evanston, Illinois |
| Authorized Official Name and Position | Jennifer C. Panning (PRESIDENT) |
| Authorized Official Contact | 8478640600 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
636 Church St Ste 520 Evanston IL 60201-4581 Ph: (847) 864-0600 | 636 Church St. Ste. 510 Evanston IL 60201-4508 Ph: (847) 864-0600 |
| NPI Number | 1326440454 |
|---|---|
| Provider Enumeration Date | 09/19/2014 |
| Last Update Date | 04/06/2022 |
| Certification Date | 04/06/2022 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1326440454 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103T00000X | Psychologist | 71-006778 (Illinois) | Secondary |
| 103TC0700X | Psychologist - Clinical | (* (Not Available)) | Primary |
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