Provider Demographics
NPI:1033158514
Name:GUST, JEAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:
Last Name:GUST
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 GRISWOLD ST
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-1666
Mailing Address - Country:US
Mailing Address - Phone:248-470-3346
Mailing Address - Fax:248-912-0208
Practice Address - Street 1:650 GRISWOLD ST
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-1666
Practice Address - Country:US
Practice Address - Phone:248-470-3346
Practice Address - Fax:248-912-0208
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009874103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680F332900OtherBLUE CROSS BLUE SHIELD MI
MI0N43600Medicare ID - Type Unspecified