Provider Demographics
NPI:1053518837
Name:PANICH, JEAN CATHERINE (PHD)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:CATHERINE
Last Name:PANICH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 N 63RD ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53213-4138
Mailing Address - Country:US
Mailing Address - Phone:414-475-6631
Mailing Address - Fax:
Practice Address - Street 1:313 N 63RD ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53213-4138
Practice Address - Country:US
Practice Address - Phone:141-477-2289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-27
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2673-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical