Provider Demographics
NPI:1093252769
Name:GAGNON, JENNIFER (MED, LPC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:GAGNON
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 S FANNIN ST
Mailing Address - Street 2:SUITE 109
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-3775
Mailing Address - Country:US
Mailing Address - Phone:214-537-8433
Mailing Address - Fax:
Practice Address - Street 1:101 S FANNIN ST
Practice Address - Street 2:SUITE 109
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-3775
Practice Address - Country:US
Practice Address - Phone:214-537-8433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-19
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX73922101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional