Provider Demographics
NPI:1447588918
Name:GIFFORD, JENNIFER REBECCA (MS, LADC)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:REBECCA
Last Name:GIFFORD
Suffix:
Gender:F
Credentials:MS, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 WILLOW ST W
Mailing Address - Street 2:SUITE #1
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-3922
Mailing Address - Country:US
Mailing Address - Phone:218-844-5191
Mailing Address - Fax:218-844-5193
Practice Address - Street 1:115 WILLOW ST W
Practice Address - Street 2:SUITE #1
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3922
Practice Address - Country:US
Practice Address - Phone:218-844-5191
Practice Address - Fax:218-844-5193
Is Sole Proprietor?:No
Enumeration Date:2009-11-21
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302760101YA0400X
101YP2500X
MN436787101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool