Healthcare Provider Details

I. General information

NPI: 1275952285
Provider Name (Legal Business Name): GAYLA IGNACIO M.A./L.L.P.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2014
Last Update Date: 04/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1206 CLINTON RD
JACKSON MI
49202-2005
US

IV. Provider business mailing address

1206 CLINTON RD
JACKSON MI
49202-2005
US

V. Phone/Fax

Practice location:
  • Phone: 517-783-4250
  • Fax:
Mailing address:
  • Phone: 517-783-4250
  • Fax: 517-783-4164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401012612
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: