Basic Information
| Provider Information | |||||||||
| NPI: | 1376084822 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONNER | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PSY.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RENO | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10 GRAHAM RD W | ||||||||
| Address2: | |||||||||
| City: | ITHACA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148501055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072572188 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10 GRAHAM RD W | ||||||||
| Address2: | |||||||||
| City: | ITHACA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148501055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072572188 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2017 | ||||||||
| LastUpdateDate: | 10/10/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 023424 | NY | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.