1902966518 NPI number — MRS. JENNIFER GALE GILLETTE LMSW, OSW-C

Table of content: MRS. JENNIFER GALE GILLETTE LMSW, OSW-C (NPI 1902966518)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902966518 NPI number — MRS. JENNIFER GALE GILLETTE LMSW, OSW-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GILLETTE
Provider First Name:
JENNIFER
Provider Middle Name:
GALE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMSW, OSW-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902966518
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1157 SHADOW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48085-1779
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-224-2930
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22301 FOSTER WINTER DR
Provider Second Line Business Practice Location Address:
3RD FLOOR
Provider Business Practice Location Address City Name:
SOUTHFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48075-3707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-849-3243
Provider Business Practice Location Address Fax Number:
248-849-2919
Provider Enumeration Date:
12/12/2006

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: 1041C0700X , with the licence number:  6801081393 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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