MEDICARE: JIEUN GU M. A., LPC

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	101YM0800X	Mental Health Counselor
2	101YP2500X	Professional Counselor	PC016070	PA

General Provider Information

NPI Number	:	1831649367
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JIEUN GU M. A., LPC

Provider Business Mailing Address
First Line	:	1859 N 52ND ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19131-3310
Country	:	US
Telephone Number	:	612-655-9753
Fax Number	:

Provider Business Practice Location Address
First Line	:	1859 N 52ND ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19131-3310
Country	:	US
Telephone Number	:	612-655-9753
Fax Number	:

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

Provider Enumeration Date	:	10/07/2016
Last Update Date	:	09/11/2023

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