MEDICARE: JENNY GUSTAFSON

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	103K00000X	Behavior Analyst	1-14-16819	TN

General Provider Information

NPI Number	:	1700266137
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNY GUSTAFSON

Provider Business Mailing Address
First Line	:	1806 15TH AVE S
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37212-3904
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1806 15TH AVE S
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37212-3904
Country	:	US
Telephone Number	:	615-828-2191
Fax Number	:

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

Provider Enumeration Date	:	06/01/2015
Last Update Date	:	06/01/2015

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