Provider Demographics
NPI:1316223076
Name:JAXIE GUNNER, INC.
Entity Type:Organization
Organization Name:JAXIE GUNNER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAXIE
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:GUNNER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:724-980-1504
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:
Mailing Address - Fax:724-212-3345
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:724-212-3345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0165141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102458480-0001Medicaid