1629064662 NPI number — MRS. JANE CAROLYN GUNNISON MSW

Table of content: MRS. JANE CAROLYN GUNNISON MSW (NPI 1629064662)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629064662 NPI number — MRS. JANE CAROLYN GUNNISON MSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUNNISON
Provider First Name:
JANE
Provider Middle Name:
CAROLYN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KREMPA
Provider Other First Name:
JANE
Provider Other Middle Name:
CAROLYN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1629064662
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4881 SUGAR MAPLE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WPAFB
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45433-5546
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-257-6429
Provider Business Mailing Address Fax Number:
937-656-1402

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4881 SUGAR MAPLE DR
Provider Second Line Business Practice Location Address:
5TH FLOOR
Provider Business Practice Location Address City Name:
WPAFB
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45433-5546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-257-6429
Provider Business Practice Location Address Fax Number:
937-656-1402
Provider Enumeration Date:
09/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  LISW 1915 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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