Provider Demographics
NPI:1437660248
Name:GOTTSCHALK, JAY RANDALL (PHD, APRN, PMHNP-BC)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:RANDALL
Last Name:GOTTSCHALK
Suffix:
Gender:M
Credentials:PHD, APRN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 SERVICE RD STE A109B
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7015
Mailing Address - Country:US
Mailing Address - Phone:517-353-3070
Mailing Address - Fax:517-884-1817
Practice Address - Street 1:804 SERVICE RD STE A110
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824-7015
Practice Address - Country:US
Practice Address - Phone:517-353-8122
Practice Address - Fax:517-432-3713
Is Sole Proprietor?:No
Enumeration Date:2017-10-19
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704296264364SP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health