Provider Demographics
NPI:1306196761
Name:CUNNINGHAM, JEAN A (PHD)
Entity type:Individual
Prefix:DR
First Name:JEAN
Middle Name:A
Last Name:CUNNINGHAM
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 1:24 E BAY CT
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-7990
Mailing Address - Country:US
Mailing Address - Phone:618-549-6597
Mailing Address - Fax:
Practice Address - Street 1:231 W MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-2948
Practice Address - Country:US
Practice Address - Phone:618-549-6597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-003190103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical