MEDICARE: JENNIFER GUSTAFSON AMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist

General Provider Information

NPI Number	:	1174251839
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER GUSTAFSON AMFT

Provider Business Mailing Address
First Line	:	1340 E PALM ST
Second Line	:
City	:	ALTADENA
State	:	CA
Zip	:	91001-2042
Country	:	US
Telephone Number	:	626-824-6699
Fax Number	:

Provider Business Practice Location Address
First Line	:	1340 E PALM ST
Second Line	:
City	:	ALTADENA
State	:	CA
Zip	:	91001-2042
Country	:	US
Telephone Number	:	626-824-6699
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/10/2022
Last Update Date	:	08/10/2022

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