Provider Demographics
NPI:1063878577
Name:PENCROFT PSYCHOLOGY ASSOCIATES LLC
Entity type:Organization
Organization Name:PENCROFT PSYCHOLOGY ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:JENISON
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:515-218-1901
Mailing Address - Street 1:2213 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-5305
Mailing Address - Country:US
Mailing Address - Phone:515-237-3974
Mailing Address - Fax:515-883-2692
Practice Address - Street 1:2600 GRAND AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50312-5375
Practice Address - Country:US
Practice Address - Phone:515-218-1901
Practice Address - Fax:515-274-6913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-13
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA006791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty