Provider Demographics
NPI:1407009046
Name:GUSTAFSON-STEPHENSON, JENNIFER LOUISE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LOUISE
Last Name:GUSTAFSON-STEPHENSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:STEPHENSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BSW, MSW
Mailing Address - Street 1:43 S LUBEC RD
Mailing Address - Street 2:
Mailing Address - City:LUBEC
Mailing Address - State:ME
Mailing Address - Zip Code:04652-3620
Mailing Address - Country:US
Mailing Address - Phone:207-733-1090
Mailing Address - Fax:207-733-2847
Practice Address - Street 1:43 S LUBEC RD
Practice Address - Street 2:
Practice Address - City:LUBEC
Practice Address - State:ME
Practice Address - Zip Code:04652-3620
Practice Address - Country:US
Practice Address - Phone:207-733-1090
Practice Address - Fax:207-733-2847
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801886871041C0700X
MEMC135631041C0700X
MELC151351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMC13563OtherSTATE OF MAINE
MELC15135OtherLCSW
MI680188687OtherSTATE OF MICHIGAN