Provider Demographics
NPI:1285831297
Name:JERVIS-WHITE, GWENDOLYN THERESA (MS)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:THERESA
Last Name:JERVIS-WHITE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:347 FLORIDA ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14208-1330
Mailing Address - Country:US
Mailing Address - Phone:716-886-1125
Mailing Address - Fax:
Practice Address - Street 1:80 GOODRICH ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1005
Practice Address - Country:US
Practice Address - Phone:716-859-2118
Practice Address - Fax:716-859-1505
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health