| Doctor Name: | DR. JACOB PANQUALE PANZARELLA |
| NPI Number: | 1164738464 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | PH.D. |
| License Number: | PSY3581 |
| Business Practice Address: | 4040 Civic Center Dr Suite 200 San Rafael, CA - 949034150 |
| Business Phone Number: | 4153810300 |
| Business Fax Number: | 4158984361 |
| Mailing Address: | 775 E Blithedale Ave, Box 402 MILL VALLEY |
| State: | CA |
| Postal Code: | 949411554 |
| Phone Number: | 4153810300 |
| Fax Number: | 4158984361 |
| NPI Enumeration Date: | 08/24/2010 |
| NPI Last Update Date: | 08/24/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103G00000X |
| License Number: | PSY3581 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | CA |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Clinical Neuropsychologist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual with a doctorate degree, licensure in clinical psychology and specialized training or board certification in neuropsychology who practices or adheres to the principles of neuropsychology; a specialty within the field of psychology focusing primarily on neurobehavioral functioning. |