Healthcare Provider Details

I. General information

NPI: 1457859787
Provider Name (Legal Business Name): JOHNENE ANN GASTON BC-HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2018
Last Update Date: 02/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2266 SPRINGPORT RD UNIT D
JACKSON MI
49202-1454
US

IV. Provider business mailing address

2266 SPRINGPORT RD UNIT D
JACKSON MI
49202-1454
US

V. Phone/Fax

Practice location:
  • Phone: 517-788-8000
  • Fax: 517-788-3898
Mailing address:
  • Phone: 517-788-8000
  • Fax: 517-788-3898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number3208
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: