Provider Demographics
NPI:1548605728
Name:GOZDZIALSKI, JENNIFER RAE (MAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RAE
Last Name:GOZDZIALSKI
Suffix:
Gender:F
Credentials:MAC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:RAE
Other - Last Name:GILLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MAC
Mailing Address - Street 1:810 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:KEWAUNEE
Mailing Address - State:WI
Mailing Address - Zip Code:54216-1140
Mailing Address - Country:US
Mailing Address - Phone:920-388-7044
Mailing Address - Fax:920-388-7044
Practice Address - Street 1:810 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:KEWAUNEE
Practice Address - State:WI
Practice Address - Zip Code:54216-1140
Practice Address - Country:US
Practice Address - Phone:920-388-7044
Practice Address - Fax:920-388-7044
Is Sole Proprietor?:No
Enumeration Date:2013-05-01
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1681-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health