1922054949 NPI number — MS. JENNIFER MARY GISH LICSW

Table of content: MS. JENNIFER MARY GISH LICSW (NPI 1922054949)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922054949 NPI number — MS. JENNIFER MARY GISH LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GISH
Provider First Name:
JENNIFER
Provider Middle Name:
MARY
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LICSW
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:
1922054949
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:
10560 WAYZATA BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNETONKA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55305-1524
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-595-0562
Provider Business Mailing Address Fax Number:
952-595-0564

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10560 WAYZATA BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MINNETONKA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55305-1524
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-595-0562
Provider Business Practice Location Address Fax Number:
952-595-0564
Provider Enumeration Date:
05/25/2006

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:  1866 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 127674 . This is a "BEHAVIORAL HEALTH CARE PR" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP30670 . This is a "HEALTH PARTNERSW" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 167437 . This is a "COMPSYCH" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 6262800 . This is a "UNITED BEHAVIORAL HEALTH" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 25G83GI . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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