Provider Demographics
NPI:1356480487
Name:GAVIN, JARED DAVID (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JARED
Middle Name:DAVID
Last Name:GAVIN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15889 PRESTON RD APT 1079
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-3802
Mailing Address - Country:US
Mailing Address - Phone:214-814-4788
Mailing Address - Fax:
Practice Address - Street 1:501 S JUPITER RD
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75042-7108
Practice Address - Country:US
Practice Address - Phone:214-997-3359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3607101YM0800X
TX1054961041C0700X
NE13391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE520111977Medicaid