Provider Demographics
NPI:1285790154
Name:GHANNAM, JESS H (PHD)
Entity type:Individual
Prefix:DR
First Name:JESS
Middle Name:H
Last Name:GHANNAM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1939 DIVISADERO ST
Mailing Address - Street 2:# 3
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 1:1335 STANFORD
Practice Address - Street 2:
Practice Address - City:EMERYVILLE
Practice Address - State:CA
Practice Address - Zip Code:94608-2536
Practice Address - Country:US
Practice Address - Phone:510-647-5101
Practice Address - Fax:510-647-5105
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY9261103G00000X, 103T00000X, 103TC0700X, 103TF0200X, 103TP2701X, 103TR0400X, 2084P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
No2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ20562ZOtherGROUP ID NUMBER
CA943307488OtherGROUP TAX ID NUMBER
CA943307488OtherGROUP TAX ID NUMBER
CAZZZ20562ZOtherGROUP ID NUMBER