=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326829631
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JENNIFER GAUVIN LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2023
-----------------------------------------------------
Last Update Date | 03/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 164 N MAIN ST
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48170-1236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-335-0431
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21456 SUMMERSIDE LN
-----------------------------------------------------
City | NORTHVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48167-1026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-719-4498
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER / AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | JENNIFER N GAUVIN
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 586-719-4498
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------