Provider Demographics
NPI:1508509167
Name:GAGNON, JENNIFER (CDCA, APS)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:GAGNON
Suffix:
Gender:F
Credentials:CDCA, APS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5730 ROCHE DR APT D
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43229-4237
Mailing Address - Country:US
Mailing Address - Phone:678-580-8970
Mailing Address - Fax:
Practice Address - Street 1:7400 HUNTINGTON PARK DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43235-5617
Practice Address - Country:US
Practice Address - Phone:678-580-8970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-20
Last Update Date:2024-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.183569101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)