Provider Demographics
NPI:1235498353
Name:GUSTAVSON-DUFOUR, JENNIFER ANN (LMFT #98554)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:GUSTAVSON-DUFOUR
Suffix:
Gender:F
Credentials:LMFT #98554
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5691 LONE PINE PL
Mailing Address - Street 2:
Mailing Address - City:PASO ROBLES
Mailing Address - State:CA
Mailing Address - Zip Code:93446-7387
Mailing Address - Country:US
Mailing Address - Phone:805-226-6466
Mailing Address - Fax:
Practice Address - Street 1:2000 TRAFFIC WAY
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-1523
Practice Address - Country:US
Practice Address - Phone:805-464-4660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-09
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA98554106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA98554OtherLICENSED MARRIAGE AND FAMILY THERAPIST