Provider Demographics
NPI:1306005368
Name:GUNNER, JAXIE KAY (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:JAXIE
Middle Name:KAY
Last Name:GUNNER
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:KAY
Other - Middle Name:
Other - Last Name:GUNNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:408 8TH ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:NEW KENSINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15068-6426
Mailing Address - Country:US
Mailing Address - Phone:724-980-1504
Mailing Address - Fax:
Practice Address - Street 1:408 8TH ST
Practice Address - Street 2:SUITE 5
Practice Address - City:NEW KENSINGTON
Practice Address - State:PA
Practice Address - Zip Code:15068-6426
Practice Address - Country:US
Practice Address - Phone:724-980-1504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0165141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102458480-0001Medicaid