Healthcare Provider Details

I. General information

NPI: 1750648416
Provider Name (Legal Business Name): JENNIFER BERGOUHI GAEBE LCSW 117785
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2012
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1204 W SHAW AVE # 102
FRESNO CA
93711-3706
US

IV. Provider business mailing address

2550 W CLINTON AVE BLDG W
FRESNO CA
93705-4206
US

V. Phone/Fax

Practice location:
  • Phone: 559-906-0699
  • Fax:
Mailing address:
  • Phone: 559-264-7521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCADC-CAS
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW117785
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: